Alaska Medicaid MMIS Claim Exception Codesmanuals.medicaidalaska.com/docs/dnld/Update...1 of 35 Rev. 4/9/2019 Alaska Medicaid MMIS Claim Exception Codes Code Description 0004 The member

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Rev. 4/9/2019

Alaska Medicaid MMIS Claim Exception Codes

Code Description

0004 The member for which the claim is being adjudicated has a claim already in process.

1000 The batch type code on the claim is invalid.

1020 Diagnosis Code not allowed as principal diagnosis

1030 The Billing Provider Number is missing or invalid.

1040 The billing provider taxonomy is missing or invalid.

1045 The Rendering Provider Taxonomy is missing or invalid.

1050 The Provider Signature is missing.

1051 The Provider Signature Date is missing or invalid.

1060 The Payee Designation Code is missing or invalid.

1065 EOB on claim line is invalid

1066 EOB on claim header is invalid

1067 Exception Override Code on claim Line is invalid

1068 Exception Override Code on claim is invalid

1070 The Assignment or Plan Participation Code is missing or invalid.

1080 The Header Level Override Location Code is invalid.

1090 The Header Remark Code is invalid.

1100 This Claim Type is set to Super Suspend.

1110 Special batch number indicates Fiscal Agent Review is required.

1120 The Remark Code Line Item is invalid.

1130 The From Service Date on Claim Header is Missing or Invalid.

1131 The From Service Date on Claim Line is Missing or Invalid.

1140 The Through Service Date on Claim Header is Missing or Invalid.

1141 The Through Service Date on Claim Line is Missing or Invalid.

1150 The From Date of Service on Claim Header is after the Through Date of Service on Claim Header.

1151 The From Date of Service on Claim Line is after the Through Date of Service on Claim Line.

1160 The Through Date of Service on Claim Header is after Receipt Date of the Claim.

1161 The Through Date of Service on Claim Line is after Receipt Date of the Claim.

1171 The Accident Date on Claim Line is after Through Date of Service on the Claim.

1180 Date of Service Cannot Span Across Months.

1190 The Provider Signature Date is greater than Receipt Date.

1200 The Provider Signature Date on the claim is before the header last date of service.

1201 The Provider Signature Date on the claim is before the line item last date of service.

1212 Crossover Claim exceeds timely filing and no proof of timely filing attached

1215 Request for additional information not received within time limit

1230 Claim Line Item dates of SVC span State Fiscal Year

1240 The Submitted Units of Service is missing or invalid.

1250 The submitted charge is zero

1260 The sum of the line item billed charges is not equal to the total submitted charges

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Code Description

1270 The net claim charge is not equal to the calculated net claim charge (Total Charge Amount - TPL Amounts).

1280 The claim header total TPL amount exceeds the claim header total charge.

1290 A Medical Diagnosis is required.

1300 HIPAA attachment code is present on Electronic Claim and an attachment was not received.

1301 A HIPAA Attachment Type Code was submitted at the claim header, but no attachment was received.

1303 HIPAA attachment code is present on Electronic Claim and an attachment was not received.

1304 A HIPAA Attachment Type Code was submitted at the claim line item, but no attachment was received.

1310 Line of Business Code is missing or could not be determined.

1320 The Submitted Member ID Number is not present

1330 The Member Name is missing.

1340 The Member Date of Birth is not a valid date.

1350 The first procedure code modifier is not valid.

1351 The second procedure code modifier is not valid.

1352 The third procedure code modifier is not valid.

1353 The fourth procedure code modifier is not valid.

1360 The Place of service on the claim line item is not present

1370 The Diagnosis Related Code is repeated or missing or invalid.

1380 The Code for Related Cause 1 is invalid

1381 The Code for Related Cause 2 is invalid

1390 The Procedure Code is missing.

1400 The Tooth Number is not valid.

1401 Area of Oral Cavity Invalid

1410 The first Tooth Surface is not valid.

1411 The second Tooth Surface is not valid.

1412 The third Tooth Surface is not valid.

1413 The fourth Tooth Surface is not valid.

1414 The fifth Tooth Surface is not valid.

1420 The Type of Bill is missing or invalid.

1430 The source of admission is missing or invalid.

1440 The Admission Type is invalid.

1450 The Admitting Diagnosis is missing.

1455 Invalid submit of Admit Diag

1460 The Admission Date is missing or invalid.

1462 The Admit Date is less than the First Date of Service

1470 The Claim Admission Date is after From Date of Service.

1480 The Admission Hour is missing or invalid.

1490 The Revenue Code is missing.

1500 The Line Item Date of Service is outside the Header From or Through Dates.

1510 Missing or Invalid Covered Days and/or Non-Covered Days conflicts with patient status indicated on the claim.

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Code Description

1520 The Patient Status conflicts with billing frequency.

1521 The fourth character in type of bill (billing frequency) is 7 or 8 indicating an adjustment.

1530 There is a Non-Covered Charge Conflict. The total submitted charges must include the total non-covered charges.

1550 The Surgery date is missing or not within header From and Through Date of Service.

1560 Inpatient Admission is Less Than 24 Hours

1570 The Discharge Hour is missing or invalid.

1580 The Operating Physician Number is missing.

1590 The Attending Physician Number is missing.

1600 The Patient Discharge Status is missing or invalid.

1601 The first Surgical Procedure Code is missing and the corresponding date is present.

1602 The second Surgical Procedure Code is missing and the corresponding date is present.

1603 The third Surgical Procedure Code is missing and the corresponding date is present.

1604 The fourth Surgical Procedure Code is missing and the corresponding date is present.

1605 The fifth Surgical Procedure Code is missing and the corresponding date is present.

1606 The sixth Surgical Procedure Code is missing and the corresponding date is present.

1607 The seventh Surgical Procedure Code is missing and the corresponding date is present.

1608 The eighth Surgical Procedure Code is missing and the corresponding date is present.

1609 The ninth Surgical Procedure Code is missing and the corresponding date is present.

1610 The tenth Surgical Procedure Code is missing and the corresponding date is present.

1611 The eleventh Surgical Procedure Code is missing and the corresponding date is present.

1612 The twelfth Surgical Procedure Code is missing and the corresponding date is present.

1613 The thirteenth Surgical Procedure Code is missing and the corresponding date is present.

1614 The fourteenth Surgical Procedure Code is missing and the corresponding date is present.

1615 The fifteenth Surgical Procedure Code is missing and the corresponding date is present.

1616 The sixteenth Surgical Procedure Code is missing and the corresponding date is present.

1617 The seventeenth Surgical Procedure Code is missing and the corresponding date is present.

1618 The eighteenth Surgical Procedure Code is missing and the corresponding date is present.

1619 The nineteenth Surgical Procedure Code is missing and the corresponding date is present.

1621 The twentieth Surgical Procedure Code is missing and the corresponding date is present.

1622 The twenty-first Surgical Procedure Code is missing and the corresponding date is present.

1623 The twenty-second Surgical Procedure Code is missing and the corresponding date is present.

1624 The twenty-third Surgical Procedure Code is missing and the corresponding date is present.

1625 The twenth-fourth Surgical Procedure Code is missing and the corresponding date is present.

1630 Total Days Billed does not equal the Number of Days between the From and Through Dates of Service.

1640 The 1st Condition Code is invalid.

1641 The 2nd Condition Code is Invalid.

1642 The 3rd Condition Code is Invalid.

1643 The 4th Condition Code is Invalid.

1644 The 5th Condition Code is Invalid

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Code Description
















1660 The 21st Condition Code is Invalid.

1661 The 22nd Condition Code is Invalid.

1662 The 23rd Condition Code is Invalid.


1670 The 1st Surgery Procedure Code Present and Date Missing or Invalid.

1671 The 2nd Surgery Procedure Code Present and Date Missing or Invalid.

1672 The 3rd Surgery Procedure Code Present and Date Missing or Invalid.

1673 The 4th Surgery Procedure Code Present and Date Missing or Invalid.

















1690 The 21st Surgery Procedure Code Present and Date Missing or Invalid.

1691 The 22nd Surgery Procedure Code Present and Date Missing or Invalid.

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Code Description

1692 The 23rd Surgery Procedure Code Present and Date Missing or Invalid.


1695 Screenings, Assessment, and POC req referral number

1700 The 1st Occurrence Span Code is Invalid.

1701 The 2nd Occurrence Span Code is nvalid.

1702 The 3rd Occurrence Span Code is Invalid

1703 The 4th Occurrence Span Code is Invalid

















1720 The 21st Occurrence Span Code is Invalid

1721 The 22nd Occurrence Span Code is Invalid

1722 The 23rd Occurrence Span Code is Invalid


1730 The 1st Occurrence Span Code requires a Valid Begin and End Date or the Occurrence Span Begin and End Dates require a valid Occurrence Span Code

1731 The 2nd Occurrence Span Code requires a Valid Begin and End Date or the Occurrence Span Begin and End Dates require a valid Occurrence Span Code

1732 The 3rd Occurrence Span Code requires a Valid Begin and End Date or the Occurrence Span Begin and End Dates require a valid Occurrence Span Code

1733 The 4th Occurrence Span Code requires a Valid Begin and End Date or the Occurrence Span Begin and End Dates require a valid Occurrence Span Code





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Code Description













1750 The 21st Occurrence Span Code requires a Valid Begin and End Date or the Occurrence Span Begin and End Dates require a valid Occurrence Span Code

1751 The 22nd Occurrence Span Code requires a Valid Begin and End Date or the Occurrence Span Begin and End Dates require a valid Occurrence Span Code

1752 The 23rd Occurrence Span Code requires a Valid Begin and End Date or the Occurrence Span Begin and End Dates require a valid Occurrence Span Code


1760 The 1st Occurrence Code is Invalid

1761 The 2nd Occurrence Code is Invalid

1762 The 3rd Occurrence Code is Invalid

1763 The 4th Occurrence Code is Invalid










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Code Description








1780 The 21st Occurrence Code is Invalid

1781 The 22nd Occurrence Code is Invalid

1782 The 23rd Occurrence Code is Invalid


1790 The 1st Occurrence Code requires a Valid Date or the Occurrence Date require a valid Occurrence Code

1791 The 2nd Occurrence Code requires a Valid Date or the Occurrence Date require a valid Occurrence Code

1792 The 3rd Occurrence Code requires a Valid Date or the Occurrence Date require a valid Occurrence Code

1793 The 4th Occurrence Code requires a Valid Date or the Occurrence Date require a valid Occurrence Code














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Code Description




1810 The 21st Occurrence Code requires a Valid Date or the Occurrence Date require a valid Occurrence Code

1811 The 22nd Occurrence Code requires a Valid Date or the Occurrence Date require a valid Occurrence Code

1812 The 23rd Occurrence Code requires a Valid Date or the Occurrence Date require a valid Occurrence Code


1820 The 1st Value Code is Invalid

1821 The 2nd Value Code is Invalid

1822 The 3rd Value Code is Invalid

1823 The 4th Value Code is Invalid

















1840 The 21st Value Code is Invalid

1841 The 22nd Value Code is Invalid

1842 The 23rd Value Code is Invalid


1850 The 1st Value Code requires a Valid Amount or the Valid Amount requires a valid Value Code

1851 The 2nd Value Code requires a Valid Amount or the Valid Amount requires a valid Value Code

1852 The 3rd Value Code requires a Valid Amount or the Valid Amount requires a valid Value Code

1853 The 4th Value Code requires a Valid Amount or the Valid Amount requires a valid Value Code


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Code Description
















1870 The 21st Value Code requires a Valid Amount or the Valid Amount requires a valid Value Code

1871 The 22nd Value Code requires a Valid Amount or the Valid Amount requires a valid Value Code

1872 The 23rd Value Code requires a Valid Amount or the Valid Amount requires a valid Value Code


1880 Claim is pending for Review Due to Notes

1881 Global Obstetric Care (proc code 59400) is not allowed without TPL

1882 Claim exceed timely filing and no proof of timely filing attached

1885 Sum of days / hours exceed dates of service.

1890 The TCN requested to be Voided matches a Claim that has been previously Denied. No Void can be made.

1891 The Requested Void or Replacement TCN is Missing or Invalid. The Request cannot be processed.

1892 The Requested Void or Replacement is already in process for this Claim. The Request cannot be processed.

1893 The Member ID on the Requested Void or Replacement TCN does not match the Member ID on the TCN

1894 The Requested Void or Replacement has already been Voided or Replaced. The Request cannot be processed.

1895 The TCN to be Replaced or Voided does not match a previously adjudicated Claim in history.

1896 The Requested Void or Replacement is a Financial Transaction. Financial Transactions cannot Be Voided or Replaced.

1897 The requested TCN to be Replaced is already Voided. A Void cannot be Voided or Replaced. The Request cannot be processed.

1898 The Adjustment Reason Code is Missing

1899 The Receipt Financial Control Number entered on the Replacement Request is Not on File.

1900 The Provider Number on the FCN does not equal the Billing Provider on the "To be Replaced" Claim.

1901 The Receipt Financial Reason Code on the FCN is not a valid Receipt Code. Requests for Void or Replacement cannot be posted against this FCN.

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Code Description

1902 The Receipt Financial Control Number entered on the Adjustment Request has a Financial Balance Amount of Zero.

1904 The Electronic Adjustment Request contains an Error and will be marked as Denied.

1905 The Billing Provider ID submitted on the Claim to be Replaced does not equal the Billing Provider ID entered on the Replacement Request

1907 The Claim to be Replaced or Voided has a status of Suspended and Suspended Claims cannot be Voided or Replaced.

1908 The Claim to be Replaced or Voided is a Pharmacy Claim and Pharmacy Claims cannot be Voided or Replaced. The Request cannot be processed.

1909 The Billing Provider ID for the Void or Replacement is Missing or Invalid. The Request cannot be processed.

1910 The Provider ID Type for the Void or Replacement is Missing or Invalid.

1911 The Member ID for the Void or Replacement is Missing or Invalid.

1915 The Void or Adjustment Financial Control Number is required for the selected Adjustment Reason Code.

1916 TCN being adjusted is denied

1917 REPLACED TCN HAS BEEN LOCKED AND CANT BE ADJUSTED

1920 The Medicare Paid Date is missing or invalid

1921 Crossover Claim Requires Medicare EOMB Attachment

1922 EOMB Requires Review

1930 The Medicare Payment Date is before the Through Date of Service or after the Receipt Date of the claim

1931 The first occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1932 The second occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1933 The third occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1934 The fourth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1935 The fifth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1936 The sixth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1937 The seventh occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1938 The eighth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1939 The nineth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1940 The tenth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1941 The eleventh occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1942 The twelfth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

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Code Description

1943 The thirteenth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1944 The fourteenth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1945 The fifteenth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1946 The sixteenth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1947 The seventeenth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1948 The eighteenth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1949 The nineteenth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1950 The Sum of the Deductible and/or Coinsurance Amounts is greater than the Medicare Allowed Amount

1951 The twentieth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1952 The twenty-first occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1953 The twenty-second occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1954 The twenty-third occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1955 The twenty-fourth occurrence code has a value of 50 and the FDOS is less than the associated occurrence code date.

1961 Outpatient claims line cannot span more than one Date of Service per claim

1962 Tribal Outpatient claim cannot span multiple days unless there is an emergency or observation revenue code

1970 The member ID submitted on the claim is not numeric.

1971 Admit Type/Admit Source conflict

1973 Non-Covered Charge greater than submitted charge

1974 Covered days is zero

1975 Admit source is invalid for admit type of newborn.

1976 Admit Type Invalid for LTC admission

1977 Total claim charge not equal to sum of total covered charges and total non-covered charges.

1978 Accident date after admit date

1980 The total paid by Medicare is greater than the total amount billed.

1982 The batch date is more than 1 year greater than the last date of service on the claim and there is proof of timely filing attached to the claim.

1985 The net charge billed by Medicare does not equal the sum of the patient responsibility amounts.

1990 The claim is a crossover and the batch date is more than 1 year greater than the last date of service on the claim and there is proof of timely filing attached to the claim.

1992 Total submitted charge is zero.

1994 There is no Deductible or Coinsurance On Crossover Claim submitted

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Code Description

1995 Medicare paid amount is zero

1996 Service dates cannot cross pricing

1997 Billing Provider ID is missing or Invalid on replaced Claim

1998 Fund Code is missing or Invalid on replaced Claim Header or Line

2000 The Member ID submitted on the claim is not on file w/o attachment

2001 The Member ID submitted on the claim is not on file w/o attachment, already recycled.

2002 The Member ID submitted on the claim is not on file, with attachment.

2004 The Dates of Service on the claim are prior to the Member's eligibility begin date, w/o attachment

2005 The Dates of Service on the claim are prior to the Member's eligibility begin date

2006 The Dates of Service on the claim are after the Member's eligibility end date.

2007 The Dates of Service on the claim are after the Member's eligibility end date

2008 The Member's eligibility does not cover the entire period between the From and the Through Dates of Service on the claim.

2009 The Member's eligibility does not cover the entire period between the From and the Through Dates of Service on the claim.

2010 Member Not Eligible Prior to Coverage with attachment

2011 DOS After Member Elig End Date with attachment

2015 The Member name on the claim does not match the Member name on file

2020 One or more Dates of Service on the claim are after the Member's Date of Death

2021 Line Item Revenue Code is 0235 and Member Date of Death minus Claim Date of Service > 7 days.

2025 The Patient Status on the claim conflicts with the Member Date of Death on file

2030 The Date of Service submitted on the claim is prior to the Member's Date of Birth on file

2031 The date of birth on the member detail table is missing.

2040 The Date of Birth on the claim does not match Date of Birth on file

2045 The Gender of the Member is unknown

2100 One or more Dates of Service on the claim are not covered on the Member's Long Term Care segment.

2104 Dates of Service on the claim are not covered on the Member's Long Term Care segment.

2105 Dates of Service on the claim are not covered on the Member's Long Term Care segment - Recycle

2109 The Provider is not authorized by Nursing Home Span for submitted Date of Service.

2130 The Member's Nursing Home Patient Liability Date Segments do not cover the Dates of Service on the claim.

2200 No Hospice Lock-In is available for Dates of Service

2310 The revenue code billed on the claim line does not match the level of care of the member.

2950 Payment cannot be made. The Member is locked into another Provider.

2951 Payment cannot be made. The Member is locked out from this Provider.

2952 Member on review per your request.

2953 Payment cannot be made. The Member is locked into another Dental Provider.

2955 Member locked into another pharmacy provider

2957 Member Incarcerated during DOS

2958 Service not covered for DOC member

2960 Member has partial month eligibility for Medicaid

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Code Description

2965 Member has partial month eligibility for LTC and Waiver

2966 ABA DX BYPASS

2975 Member has elected hospice

2976 Member Is A Child Under Hospice Care

3000 The Billing Provider ID submitted on the claim is not on file

3001 The Billing Provider ID is not on file for the Dates of Service on the claim

3005 The Billing Provider does not have an active Enrollment Span that covers the Dates of Service on the claim.

3015 The Billing Provider ID on the Claim is not an authorized Billing Provider

3020 The Claim must be submitted Electronically

3025 The Billing Provider ID on the claim is only authorized to submit Crossover Claims.

3150 The Billing Provider NPI not on File.

3155 The claim is professional and Rendering Provider NPI not on file.

3160 The claim header dates of service span the provider's fiscal year end date

3161 The claim header dates of service span calendar years - Tribal

3175 The Rendering Provider NPI on the claim matches multiple Medicaid provider IDs

3180 Physicians Assistant requires supervising provider who is enrolled and licensed on the DOS.

3185 Individual cannot bill for another individual unless they are the employer or renderer is locum tenen.

3190 Enrollment records indicate a therapist of the same discipline is not a member of the billing group on the service date.

3191 Enrollment records indicate a Physician/Dentist is not a member of the billing group on the service date.

3192 Enrollment records indicate an active supervisor is not a member of the billing group on the service date

3193 Enrollment records indicate an active BCBA is not a member of the billing group on the service date

3194 Enrollment records indicate an active Supervisor is not a member of the billing group on the service date

3200 The Referring Provider ID submitted on the claim is not on file

3201 The Referring Provider ID is not valid for the Dates of Service on the claim

3205 The Referring Provider is not Enrolled on Date of Service.

3300 The billing provider PT is not in the system list C1-3048 and the Rendering Provider Medicaid ID Not on database

3301 The Rendering Provider ID is not on file for the Dates of Service on the claim

3305 The Rendering Provider does not have an active Enrollment Span that covers the Dates of Service on the claim.

3315 The Rendering Provider ID on the Claim is not an authorized Rendering Provider

3316 The Provider Billing Code indicates an Encounter Claim but the Claim is not an Encounter

3320 The Rendering Provider Number is not affiliated with the Billing Provider Group.

3321 The Rendering Provider Certification is Expired

3322 The Rendering Provider Grant is Expired

3323 The Rendering Provider Permit is Expired

3325 The Rendering Provider License is Expired

3326 The Rendering Provider License is Expired

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Code Description

3327 The Operating Psychiatrist's License is Expired

3328 The Pharmacist in charge of HIT License is Expired

3329 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = License. The claim last date of service is after the license expiration date.

3330 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = License. The claim last date of service minus license cert end date is after the license expiration date.

3331 Billing Provider does not have a certification on file with type of certification in effect on the date of service. Billing Provider License Record Indicator = Certificate. The claim last date of service is after the license expiration date.

3332 Billing Provider does not have a certification on file with type of certification in effect on the date of service. Billing Provider License Record Indicator = Certificate. The claim last date of service minus license cert end date is after the license expiration date.

3333 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = Grant. The claim last date of service is after the license expiration date.

3334 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = Grant. The claim last date of service minus license cert end date is after the license expiration date.

3335 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = Permit. The claim last date of service is after the license expiration date.

3336 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = Permit. Billing Provider License Record Indicator = Permit. The claim last date of service minus license cert end date is after the license expiration date.

3337 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = License

3338 Billing Provider does not have a certification on file with type of certification in effect on the date of service. Billing Provider License Record Indicator = Certificate

3339 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = Grant

3340 The Provider is not allowed to perform Professional / Technical Component

3341 Billing Provider does not have a license on file with type of license in effect on the date of service. Billing Provider License Record Indicator = Permit

3342 Rendering Provider does not have a license on file with type of license in effect on the date of service. Rendering Provider License Record Indicator = License

3343 Rendering Provider does not have a certification on file with type of certification in effect on the date of service. Rendering Provider License Record Indicator = Certificate

3344 Rendering Provider does not have a license on file with type of license in effect on the date of service. Rendering Provider License Record Indicator = Grant

3345 Rendering Provider does not have a license on file with type of license in effect on the date of service. Rendering Provider License Record Indicator = Permit

3350 Billing PT is 076 and Specialty Code is blank. Billing Provider does not have a certification on file with type of certification in effect on the date of service. Billing Provider License Record Indicator = Certificate.

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Code Description

3351 Billing PT is 108 and Specialty Code is 080. Billing Provider does not have a certification on file with type of certification in effect on the date of service. Billing Provider License Record Indicator = Certificate.

3352 Billing PT is 057 and Specialty Code is NOT 072. Billing Provider does not have a valid record on file with type of certification in effect on the date of service. Billing Provider License Record Indicator = Grant.

3353 Billing PT is 107 and Specialty Code is NOT 070. Billing Provider does not have a valid record on file with type of certification in effect on the date of service. Billing Provider License Record Indicator = Grant.

3354 Billing PT is '076'. Provider Specialty is Blank. Billing Provider does not have a Certificate Record on File. Billing Provider License Record Indicator = Certificate. The claim last date of service is after the license expiration date.

3355 Billing PT is '108'. Provider Specialty is '080'. Billing Provider does not have a valid record on File. Billing Provider License Record Indicator = Grant. The claim last date of service is after the license expiration date.

3356 Billing PT is '057'. Provider Specialty is NOT '072'. Billing Provider does not have a valid record on file. Billing Provider License Record Indicator =Certificate. The claim last date of service is after the license expiration date

3357 Billing PT is '107'. Provider Specialty is NOT '070'. Billing Provider does not have a valid record on File. Billing Provider License Record Indicator = Grant. The claim last date of service is after the license expiration date.

3358 Billing PT is '057'. Provider Specialty is NOT '072'. Billing Provider does not have a valid record on file. Billing Provider License Record Indicator = Certificate. The claim last date of service is after the license expiration date

3359 Billing PT is '107'. Provider Specialty is NOT '070'. Billing Provider does not have a valid record on File. Billing Provider License Record Indicator = Grant. The claim last date of service is after the license expiration date

3360 Billing PT is '076' (DME). Provider Specialty is Blank. Billing Provider does not have a valid record on File. Billing Provider License Record Indicator =Certificate. The claim last date of service is after the license expiration date.

3361 Billing PT is '108' (Behavioral Health Ctr). Provider Specialty is '080'. Billing Provider does not have a valid record on File. Billing Provider License Record Indicator =Grant. The claim last date of service is after the license expiration date.

3400 The Attending Provider ID submitted on the claim is not on file

3401 The Attending Provider ID is not on file for the Dates of Service on the claim

3405 The Attending Provider does not have an active Enrollment Span that covers the Dates of Service on the claim.

3600 The Category of Service cannot be determined from the information on the claim.

3615 The Billing Provider ID must be an NPI.

3616 The Billing Provider ID must be an NPI

3617 The Rendering Provider ID must be an NPI

3618 The Rendering Provider NPI is not a valid NPI number format

3620 The Billing Provider NPI matches multiple medical IDs.

3621 NPI on claim not valid for provider tax id

3622 The Attending Provider ID must be an NPI

3623 The Attending Provider NPI is not a valid NPI number format

3650 Provider Payee ID Not Found

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Code Description

3651 Waiver mod billed not valid bed count

3652 No Provider bed data on date of service

3653 No bed count on provider file

3660 The Rendering Provider Certification is Expired

3661 The Rendering Provider Grant is Expired

3662 The Rendering Provider Permit is Expired

3663 The operating psychiatrist's License is Expired

3664 The Pharmacist in charge of HIT License is Expired

3665 Billing Provider ID and qualifier are not on file

3666 Rendering Provider ID and qualifier are not on file

3667 Referring provider's NPI was submitted and the return code from the NPI lookup use case for the referring NPI indicates that the check digit is invalid

3670 The claim dates of service are past the billing provider's reverification date - suspend

3671 The claim dates of service are past the rendering provider's reverification date - suspend

3672 The claim dates of service are past the billing provider's reverification date - deny

3673 The claim dates of service are past the rendering provider's reverification date - deny

3700 Provider on review

3710 Provider on review for date of admit

3720 Prov on rev ESRD

3722 Dummy Provider Not Eligible For Payment

3730 Home Health Provider requires manual pricing

3740 Terminated for Cause-Based on Section 6501 of ACA

3750 Provider on review – School Base Services

3800 The Rendering Provider is not in any network associated to any of the Benefit Plans for the Member.

3801 The Member on claim has not been assigned any Benefit Plans covering the Dates of Service on the claim.

3802 The Billing Provider on the claim is not in any network associated to any of the Benefit Plans for the Member.

3803 Review for Medical Justification - Professional Claim Types

3804 Assistant Surgeon procedure code denied for invalid medical justification

3805 Benefit Plan Coverage does not exist for this Member for the services being billed.

3807 The Member on claim has not been assigned any Benefit Plans covering the Dates of Service on the claim within the past 30 days

3808 There is no benefit plans existing for the member within the past 30 days

3810 The submitted service on the claim is not covered by the Benefit Plan for this member.

3811 The submitted NDC units exceed

3815 There is a conflict between Benefit Plan Service Coverage and SA Requirement.

3817 New AW bed specialty CD

3825 Coverage only for CAMA benefit plan

3826 IHS Prov not elig for CAMA payments for IHS beneficiary

3827 Invalid claim type filed for QMB-only member, must be crossover

3828 Alien Medicaid coverage

17 of 35

Rev. 4/9/2019

Code Description

3829 Elig Code 25 - Eligibility Determination - Pend for Review

3830 Medicare Premium Only

3831 Waiver Detemination

3832 Medicaid Coverage - Waiver Claim excluded

3833 Place of Service exclusion

3834 Age Restriction

3836 DENTAL SVC SUBM NOT COV FOR ADULTS

3837 Enhanced Adult Dental Services

3838 Review of ASC invoice required

3839 Procedure not covered for Assistant Surgeon

3841 DME not available for purchase

3842 Provider Type not allowed as primary surgeon

3843 Tribal Clinics may not bill for CHA/P services

3844 Medical Justification required - no attachment

3845 Member is not eligible for service rendered

3846 Procedure cannot be billed by this provider

3847 Provider Cannot Submit this Invoice Type

3848 Service not covered for free standing birthing center

3849 ABA Services not covered

3850 Service not allowed for HPE Pregnant wOMEN

3851 The submitted service on the claim is not covered by the benefit plan for this member.

3852 DME Shipping Invoice Requires Review

3853 Rendering Provider for CLIA bypass

3860 Dietician Services not covered for this Member

3861 Service not covered for this member

3866 Admit Diagnosis Code Not Required

3867 Admit Dx Code Restriction

3870 Weekend Admission

3879 Services not covered for CT T

3880 Telehealth services not allowed to be billed by this provider type

3925 Professional component to pend until technical component received.

4000 The Home Infusion or Drug Procedure or Revenue Code submitted on the claim requires an NDC code

4001 The NDC on the claim line is not on file

4026 The NDC on the claim line was submitted but the Unit of Measurement was Missing or Invalid

4051 The NDC on the claim line was submitted but the Quantity was Missing or Invalid

4076 Review for Medical Justification - Professional Claim Types

4080 The Revenue Code submitted on the claim requires an attachment

4085 The Revenue Code submitted on the claim requires an attachment and there is an attachment present - requires review.

4090 The Revenue Code on the claim must be billed with a Surgical Procedure Code

18 of 35

Rev. 4/9/2019

Code Description

4095 Procedure not valid on date of service.

4096 The Procedure Code submitted on the claim is unlisted and requires written justification

4101 The Principal Diagnosis Code on the claim is missing

4105 The Diagnosis Code requires review by the State.

4110 The Member's Gender conflicts with the Principal Diagnosis submitted on the claim

4111 The Member's Age conflicts with the Principal Diagnosis submitted on the claim

4112 The Principal Diagnosis on the claim is not on file

4115 The Diagnosis Code submitted on the claim is not specific enough by itself and requires an additional Diagnosis Code

4120 The Diagnosis Code is not valid for Header Date Of Service on the claim

4121 The Diagnosis Code is not valid for Line Date Of Service on the claim

4125 The Diagnosis Code has been reviewed by the FA Staff and it has been determined that payment cannot be made.

4130 The Admitting Diagnosis submitted on the claim is not on file

4131 The Member's Age conflicts with the Admitting Diagnosis submitted on the claim

4132 The Member's Gender conflicts with the Admitting Diagnosis submitted on the claim

4133 The 1st Diagnosis Code on the claim is not on file

4134 The Member's Age conflicts with the 1st Diagnosis submitted on the claim

4135 The Member's Gender conflicts with the 1st Diagnosis submitted on the claim

4136 The 2nd Diagnosis Code on the claim is not on file

4137 The Member's Age conflicts with the 2nd Diagnosis submitted on the claim

4138 The Member's Gender conflicts with the 2nd Diagnosis submitted on the claim

4139 The 3rd Diagnosis Code on the claim is not on file

4140 The Member's Age conflicts with the 3rd Diagnosis submitted on the claim

4141 The Member's Gender conflicts with the 3rd Diagnosis submitted on the claim

4142 The Member's Age conflicts with the 4th Diagnosis submitted on the claim

4143 The Member's Gender conflicts with the 4th Diagnosis submitted on the claim

4144 The 4th Diagnosis Code on the claim is not on file














19 of 35

Rev. 4/9/2019

Code Description





























4194 he Member's Gender conflicts with the 18th Diagnosis submitted on the claim







4207 The 21st Diagnosis Code on the claim is not on file

4208 The Member's Age conflicts with the 21st Diagnosis submitted on the claim

4209 The Member's Gender conflicts with the 21st Diagnosis submitted on the claim

4210 The 22nd Diagnosis Code on the claim is not on file

4212 The Member's Age conflicts with the 22nd Diagnosis submitted on the claim

4214 The Member's Gender conflicts with the 22nd Diagnosis submitted on the claim

20 of 35

Rev. 4/9/2019

Code Description

4216 The 23rd Diagnosis Code on the claim is not on file

4218 The Member's Age conflicts with the 23rd Diagnosis submitted on the claim

4220 The Member's Gender conflicts with the 23rd Diagnosis submitted on the claim




4228 The principal diagnosis code Present on Admission (POA) Indicator was omitted when required or the POA Indicator submitted was invalid

4230 The 1st diagnosis code Present on Admission (POA) Indicator was omitted when required or the POA Indicator submitted was invalid

4231 The 2nd diagnosis code Present on Admission (POA) Indicator was omitted when required or the POA Indicator submitted was invalid

4232 The 3rd diagnosis code Present on Admission (POA) Indicator was omitted when required or the POA Indicator submitted was invalid

4233 The 4th diagnosis code Present on Admission (POA) Indicator was omitted when required or the POA Indicator submitted was invalid
















21 of 35

Rev. 4/9/2019

Code Description


4250 The 21st diagnosis code Present on Admission (POA) Indicator was omitted when required or the POA Indicator submitted was invalid

4251 The 22nd diagnosis code Present on Admission (POA) Indicator was omitted when required or the POA Indicator submitted was invalid

4252 The 23rd diagnosis code Present on Admission (POA) Indicator was omitted when required or the POA Indicator submitted was invalid


4270 The Procedure Code submitted on the claim requires a Tooth Number

4273 The Procedure Code submitted on the claim requires an Area of Oral Cavity

4274 The Procedure Code conflicts with the Tooth Number and/or oral cavity on the claim

4275 Procedure is unlisted

4278 Modifier invalid for anesthesia specialty.

4279 Modifier CC was billed on the claim line and it is a restricted modifier.

4300 The number of tooth surfaces billed on the claim is not equal to the number of tooth surfaces required on the procedure.

4302 The Patient was discharged and admitted on the same day.

4307 Procedure not allowed for LTC member

4309 A Procedure Code is required to be submitted with this Revenue Code

4314 Inpatient Claim requires an Accommodation Revenue Code(s)

4316 The Revenue Code on the Claim is not on File

4317 Accommodation revenue code not valid on outpatient claim

4318 This Revenue Code Requires Review by the State.

4320 The Member's Gender conflicts with the Revenue Code submitted on the claim

4322 There is a conflict between the Provider Type and Revenue Code submitted on the Claim.

4324 There is a conflict between the Type of Bill and Revenue Code submitted on the Claim.

4328 Lab Revenue Codes and High Tech Radiology Revenue Codes must be Billed With the Procedure Code specific to Lab or High Tech Radiology

4330 Lab Procedure Codes and High Tech Radiology Procedure Codes must be Billed with the Revenue Code specific to Lab or High Tech Radiology

4350 The NDC submitted on the claim line is not Rebateable for the Dates of Service

4375 Not covered; FDA DESI = less than effective or withdrawn

4400 The CLIA Certification Type on file for the Procedure Code submitted on the claim does not match the CLIA Provider Certification Type on the Provider file for the Dates of Service on the Claim.

4401 No CLIA Cert entry for Provider Dates of Service

4402 The Member's Age conflicts with the age range indicated on file for the Procedure Code or Surgical Procedure Code submitted on the claim

4403 The Procedure Code submitted on the claim is a Laboratory Code and the Provider billing for the services does not have a CLIA Number on file

4406 There is a conflict between the Procedure Code and Modifier 1 submitted on the claim


4410 Provider not certified for lab type

22 of 35

Rev. 4/9/2019

Code Description



4414 There is a conflict between the Procedure Code and Place of Service submitted on the claim

4415 Outside lab - no lab procs payable

4418 There is a conflict between the Procedure Code and Provider Specialty submitted on the claim

4419 There is a conflict between the Procedure Code and Provider Type submitted on the claim

4420 There is a conflict between the Claim Type and the Procedure Code submitted on the claim

4421 There is a conflict between the Procedure Code and Provider Taxonomy submitted on the claim

4422 The Procedure Code submitted on the claim requires a Modifier for billing

4423 The Claim Rendering Provider Specialty Code begin and end dates is not within the claim line begin and end dates.

4424 The Procedure Code on the claim is not on File

4425 The Member's Gender conflicts with the Procedure Code submitted on the claim

4426 The claim provider type code in SL C3-3187 and the specialty code is missing.

4427 The Procedure Code and Modifier submitted on the claim require Manual Review

4428 The Procedure Code submitted on the claim requires Review by the State.

4433 Abortion procedure, diagnosis or surgical procedure requires review

4435 Sterilization attachment needs to be reviewed

4436 A Hysterectomy Consent Form is required

4438 A Sterilization Consent Form is required and no attachment.

4439 Review the Attachment submitted with the Hysterectomy Procedure Code. A Consent Form is required.

4441 There is a conflict between the Category of Service Assigned and the Procedure Code submitted on the claim

4443 Modifier requires review

4447 The Sterilization Procedure Code submitted on the claim Requires Consent.

4448 The procedure or surgical procedure on the Reference database indicate the service is related to a sterilization and the attachment code is in system list C1-3040 (sterlization/hysterectomy attachment codes)

4449 NDC does not have Rebate span

4450 Dental Procedure only valid for one tooth

4451 Only One Time of Day Modifier can be billed per line item.

4458 Review the Attachment submitted with the Hysterectomy Diagnosis Code. A Consent Form is required.

4460 Hysterect Consent Frm Required no/att

4462 The Procedure Code on the claim must be billed with a Diagnosis Code.

4463 The Surgical Procedure Code on the claim Requires Fiscal Agent Review.

4464 The Revenue Code on the claim Requires Fiscal Agent Review.

4465 There is a conflict between the Revenue Code and Provider Specialty submitted on the claim.

4466 The Procedure Code submitted on the claim requires Review by the Fiscal Agent.

4467 Provider not certified for mammography procedure

4468 No mammography cert for DOS

23 of 35

Rev. 4/9/2019

Code Description

4469 Revenue Code age conflict

4471 Procedure is elective surgery

4472 Modifier not valid on date of service

4475 1st Surgical Procedure is not valid for date for service

4476 2nd Surgical Procedure is not valid for date for service

4477 3rd Surgical Procedure is not valid for date for service

4478 4th Surgical Procedure is not valid for date for service

















4495 21st Surgical Procedure is not valid for date for service

4496 22nd Surgical Procedure is not valid for date for service

4497 23rd Surgical Procedure is not valid for date for service


4500 The Revenue Code on the claim must be billed with a Procedure Code.

4504 The Surgical Procedure Code on the claim Requires Review By the State.

4506 The 1st Surgical Procedure Code on the claim is not on file.

4507 The Member's Gender conflicts with the 1st Surgical Procedure Code submitted on the claim.

4509 The 2nd Surgical Procedure Code on the claim is not on file.

4510 The Member's Gender conflicts with the 2nd Surgical Procedure Code submitted on the claim.

4512 The 3rd Surgical Procedure Code on the claim is not on file.

4513 The Member's Gender conflicts with the 3rd Surgical Procedure Code submitted on the claim.

4515 The 4th Surgical Procedure Code on the claim is not on file.

4516 The Member's Gender conflicts with the 4th Surgical Procedure Code submitted on the claim.





24 of 35

Rev. 4/9/2019

Code Description





4530 The Member's Gender conflicts with the 9th Surgical Procedure Code submitted on the claim

4531 The 9th Surgical Procedure Code on the claim is not on file














4552 The16th Surgical Procedure Code on the claim is not on file









4566 The Member's Gender conflicts with the 21st Surgical Procedure Code submitted on the claim

4567 The 21st Surgical Procedure Code on the claim is not on file

4569 The Member's Gender conflicts with the 22nd Surgical Procedure Code submitted on the claim

4570 The 22nd Surgical Procedure Code on the claim is not on file

4572 The Member's Gender conflicts with the 23rd Surgical Procedure Code submitted on the claim

4573 The 23rd Surgical Procedure Code on the claim is not on file



4577 The Member's Gender conflicts with the Principal Surgical Procedure Code submitted on the claim

4578 The Principal Surgical Procedure Code on the claim is not on file

4580 The Procedure Code requires medical justification - no attachment

4587 A Professional, Dental, or Institutional claims was submitted with Partial Units

4590 Surgical Procedure Requires Attachment

25 of 35

Rev. 4/9/2019

Code Description

4591 Surgical Procedure attachment requires review

4592 Surgical Procedure is unlisted with no attachment

4593 Surgical Procedure is unlisted

4594 The Claim contains both ICD 9 and ICD-10 Diagnosis codes. Only one ICD version is allowed on a claim.

4595 The Claim contains both ICD 9 and ICD-10 Surgical Procedure Codes. Only one ICD version is allowed on a claim.

4596 THE DIAGNOSIS CODE QUALIFIER OR VERSION IS NOT A VALID VALUE.

4597 THE SURGICAL PROCEDURE CODE AND ICD-10 VERSION SUBMITTED ON CLAIM DO NOT MATCH

4610 The covered days is greater than the number of days allowed for an Inpatient Stay

4611 The covered days is greater than the number of days allowed for an Inpatient Stay and SA is missing or invalid.

4614 The Revenue Code is not covered for the Claim Dates of Service.

4616 Pricing is not valid for Revenue Code for the Claim Dates of Service.

4617 The First or Last Date of Service on the Claim is outside of the Revenue Code Rate Span.

4618 This Revenue Code Requires Manual Review.

4620 This Revenue Code Requires Manual Price. There is a conflict between the Factor Code and Base Rate Source Code.

4622 This Revenue Code Requires a Price. All Pricing Methodologies have been Exhausted and the Allowed Charge is Equal to $0.00.

4626 The Sum of the Accommodation Days Does Not Equal the Total Covered Days on the Claim.

4628 Ancillary Revenue Code not paid on LTC claim.

4640 Oxygen Revenue Code requires manual price

4645 Out of State Pricing Segment not found

4646 WA physician claims for members who are less than 21

4650 The Procedure or Revenue Code on the Claim can only be Priced based on a Rate File Only Record and no Rate File Only Record was Found.

4655 Revenue Pricing Segment is set to Manual Review

4660 The Revenue Code is not covered for the Claim Dates of Service -- Weekend admission not authorized

4665 The ASC Rate is not on file does not encompass the Dates of Service on the Claim.

4670 The ASC Rate Pricing Span does not encompass the Dates of Service on the Claim.

4675 Service Must be Billed with Core Service

4680 Zero Units with greater than zero amount on claim

4685 Out of Country Claim requires manual price

4690 No Encounter Rate on File

4700 ESRD claim must contain a valid dialysis revenue code

4701 ESRD claim must contain occurrence code 50 with associated date. Revenue code requires begin date of treatment.

4702 ESRD provider type and occurrence code is 50 and FDOS equals occurrence code date with attachment. Suspend to review attachment.

4703 ESRD provider type and occurrence code is 50 and FDOS equals occurrence code date without attachment.

26 of 35

Rev. 4/9/2019

Code Description

4704 ESRD provider type and occurrence code = 24 with attachment. Suspend to review attachment.

4705 ESRD provider type and occurrence code = 24 without attachment.

4707 ESRD drug revenue codes must have a valid ESRD drug procedure code.

4708 ESRD provider type and occurrence code is 50 and FDOS does not equal occurrence code date with attachment.

4780 Valid mileage Parameter not found 18-50 miles - C3-3068

4785 Valid mileage Parameter not found >50 miles - C3-3069

4790 Final reimbursement amount is greater than the billed amount

4810 No Payment is Due from Medicaid. The Medicare Co-Insurance Amount plus the Medicare Deductible amount is not Greater Than zero.

4812 The Medicare Reimbursement Amount Exceeds the Medicaid Maximum Allowable Amount.

4814 The Manual Price Exceeds the Submitted Charge on the claim.

4815 The Service Authorization Calculated Allowed Amount Exceeds the Base Rate of the Procedure Code.

4816 The Calculated Allowed Amount is Less Than zero.

4817 The TPL Allowed amount is less than the Medicaid Allowed amount

4818 The Percent Difference between the Calculated Allowed Charge and the Submitted Charge is greater than the High Variance State-specified percent limit.

4820 The Percent Difference between the Calculated Allowed Charge and the Submitted Charge is greater than the Low Variance State-specified percent limit.

4822 The Total Charge Amount on the Claim Exceeds the Threshold Amount.

4824 The Calculated Allowed Charge Amount Exceeds the Threshold Amount.

4826 The submitted units exceed the maximum units allowed for this procedure.

4827 Procedure code's ASC group number row could not be found.

4828 The Institutional Rate record for the Provider on the Claim cannot be found or the Dates of Service on the Claim do not fall within the Institutional Rate Pricing Span.

4829 The Outpatient Institutional Rate record for the Provider on the Claim cannot be found, or the Dates of Service on the Claim do not fall within the Institutional Rate Pricing Span.

4830 The Procedure or Revenue Code on the Claim can only be Priced based on a Rate File Only Record and no Rate File Only Record was Found.

4840 Physical health encounter already paid for DOS

4845 Dental encounter already paid for DOS

4846 There is already a paid dental encounter for this member, billing provider, and date of service. EAD claim is not allowed

4850 BH encounter already paid for DOS

4855 FESC encounter exceed 6 for DOS

4857 Only CHA services or BHA services are allowed on the same claim. Rebill services on separate claims

4860 Maximum Number of Encounters Exceeded for the DOS

4865 G8 Factor Code on claim line

4871 No WAC Price on file

4885 Valid GPCIw Parameter not found

4890 Valid GPCIp Parameter not found

27 of 35

Rev. 4/9/2019

Code Description

4895 Valid GPCIm Parameter not found

4912 This Procedure Code Requires Pricing. All Pricing Methodologies have been Exhausted and the Calculated Allowed charge is zero.

4914 The Dates of Service on the Claim cannot Span more than One Day of Service.

4916 Manual pricing required for this procedure based on the factor code.

4917 The Service Authorization Allowed Amount is greater than the Billed Amount on the Claim.

4918 The Pricing Segment for the Procedure Code does not cover the Dates of Service on the Claim.

4919 The Service Authorization Allowed Amount on the Claim Exceeds the Medicaid Allowed Amount.

4920 The Procedure / Modifier Combination Pricing Segment is Not Covered on the Claim for the Dates of Service.

4921 The Service Authorization Allowed Amount on the Claim is Less Than the Medicaid Allowed Amount and Less Than the Submitted Amount on the Claim.

4922 The Procedure Factor Code indicates 'By Report'. Manual Review is Required.

4924 Procedure Rate does not have valid price for Date of Service.

4925 The Technical Component Modifier or Professional Component Modifier on the Claim does not have a Corresponding Technical or Professional Component Segment for the Procedure Code for the Dates of Service on the Claim.

4932 Claim type cannot be determined.

4950 NDC not valid on date of service

5010 The Service Authorization designated on the claim does not cover the Service (Procedure / Revenue) Code specified by the claim.

5012 SA number may be valid but does not apply to the billed services

5015 Service Authorization designated on the claim does not cover the ICD surgical procedure code specified on the inpatient claim.

5020 There is a conflict between the Line of Business and Benefit Plan assigned to the claim and the Line of Business and Benefit Plan on the Service Authorization.

5030 Service Authorization Header Status is Denied

5031 Service Authorization Line Status is Denied

5040 The Dates of Service on the Claim do not fall within the Service Authorization Begin and End Dates.

5050 The Billing Provider ID on the claim does not match the Billing Provider ID on the Service Authorization.

5051 The Billing Provider ID on the claim does not match the Billing Provider ID on the Service Authorization.

5060 The Diagnosis Code submitted on the claim does not match the Diagnosis Code specified on the Service Authorization.

5070 The Member ID submitted on the claim does not match the Member ID specified on the Service Authorization.

5090 The Billing Modifiers submitted on the claim does not match the Modifiers specified on the Service Authorization.

5100 The Tooth Number submitted on the claim does not match the Tooth Number specified on the Service Authorization.

5105 The Area of Oral Cavity submitted on the claim does not match the Area of Oral Cavity specified on the Service Authorization.

5110 The Tooth Surface submitted on the claim does not match the Tooth Surface specified on the Service Authorization.

28 of 35

Rev. 4/9/2019

Code Description

5140 The Service Authorization submitted on the Claim is not on file.

5141 Admit date outside appr dates

5160 The Service on the claim requires a Service Authorization and there is no Service Authorization on file.

5161 The claim requires authorization but does not require an SA number is submitted, the authorization ID is not submitted on the claim, the system cannot find an SA that covers the claim, and there is an attachment appropriate for SA

5170 The provider indicated the claim line item is an emergency and the claim line requires SA

5180 Service Auth ID not on claim

5190 The claim requires authorization, the authorization ID is not submitted on the claim, and there is an attachment appropriate for SA

5210 Service Authorization Header Status is Voided

5211 Service Authorization Line Status is Voided

5220 SA record is Pended w/errors - Header

5221 SA record is Pended w/errors - Line

6030 This is a Suspect Accident Related claim. The Member is under the age of 18 and the Occurrence Code or Related Cause Code on the claim indicates it is related to auto accident, other accident, another party, or employment

6031 This is a Suspect Other Accident Related claim. The Member is under the age of 18 and the Primary or Secondary Diagnosis is Accident Related.

6032 Suspect accident related claim, member over age 18 and the claim is accident related.

6033 Suspect accident related claim, member over age 18 and the claim is related to other accident, another party, or employment.

6034 This is a Suspect Other Accident Related claim. The Member is 18 years of age or older and the Primary or Secondary Diagnosis is Accident Related. Medical Service Questionnaire sent.

6035 The Occurance Code or Related Cause Code on the claim does not indicate that this is an Accident Related Claim, but the Primary or Secondary Diagnosis Code indicates it is Accident or Trauma Related.

6036 This is a Suspect Accident Related claim. The Occurrence Code or Related Cause Code on the claim indicates it is related to auto accident, other accident, another party, or employment

6050 The TPL Amount submitted on the claim is less than the TPL Threshold Percentage.

6060 TPL is indicated on the claim but no TPL Policy is found for the Member on File.

6061 TPL (EB) attachment code Indicated on Claim Form - No Resource on File

6090 The Member has Medicare Part A coverage for the Dates of Service on the claim

6091 The Member has Medicare Part A coverage for the Dates of Service on the claim. The attachment submitted requires review.

6110 The Member has Medicare Part B coverage for the Dates of Service on the claim, but no Attachment was submitted with the claim indicating an Explanation of Medicare Benefits.

6111 The Member has Medicare Part B coverage for the Dates of Service on the non crossover claim. The attachment submitted requires review.

6112 Vision Bypass Medicare Edit 6110 and 6111

6120 Mcare edits bypassed for proc not covered

6140 The Claim Type is a Inpatient Crossover, but the Member on the claim does not have Medicare Part A Coverage on file for the Dates of Service on the claim.

29 of 35

Rev. 4/9/2019

Code Description

6160 The Claim Type is a Professional Crossover, but the Member on the claim does not have Medicare Part B Coverage on file for the Dates of Service on the claim.

6280 Cost avoid for no EOB and no TPL dollars

6320 Pay & Chase for Coverage - Dental

6330 Pay & Chase for Mental Health Services

6340 Pay & Chase for Behavioral Rehab

6350 Pay & Chase for School Based Services

6360 Pay & Chase for Prenatal Diagnosis Codes

6370 Pay & Chase for Prenatal Procedure Codes

6380 Pay & Chase for Preventive Pediatric

6390 Pay & Chase for Claim Type 'W' (waiver)

6400 TPL bypass due to exhausted coverage

6410 Pay & Chase for Coverage Code AL (Vision)

6420 Cost Avoid for No EOB and has TPL dollars

6430 Cost Avoid for no TPL dollars but EOB exists

6440 Cost Avoid when TPL dollars and EOB exist

6450 Pay & Chase for Coverage Code 56 (Transportation) & Waiver

6451 TPL Avoid No Coverage

6452 TPL Avoidance

6453 TPLA Tribal

6460 Pay & Chase for Nursing Home

6470 Pay & Chase for Accomodation

6480 Pay & Chase for EPSDT

6490 Pay & Chase for Personal Care Assistan

6500 Single code edits intended to limit the number of times a procedure can be billed on a single date of service



6509 Code pairs found to be unbundled in accordance with National Correct Coding Initiative (NCCI)

6512 Code pairs found to be unbundled in accordance with National Correct Coding Initiative (NCCI) for Practitioner or ASC

6515 Invalid procedure code modifer combination

6518 Invalid procedure code non-payment modifer combination

6521 A single more comprehensive procedure exists that more acurately represents the services performed

6524 Procedures that represent overlapping services or accomplish the same result

6527 Procedure is considered incidental to the primary procedure

6530 Procedure code billed by same provider on same date of service as a code with a global period

6533 Procedure code billed by same provider on same date of service as a code with a global period

6536 Procedure codes billed by the same provider within a procedure's pre-operative period

6539 Procedure codes billed by the same provider within a procedure's pre-operative period

30 of 35

Rev. 4/9/2019

Code Description

6542 Procedure codes billed by the same provider within a procedure's post-operative period

6545 Procedure codes billed by the same provider within a procedure's post-operative period

6548 Services need to be bundled to another procedure code

6549 Procedure added due to rebundling

6552 Procedure codes with “single” or “unilateral” in the description that have been submitted more than once per date of service

6553 Replacement for all occurrences of the “single/unilateral” with the corresponding “multiple” or “bilateral” code

6556 Eligible for a pay percent reduction; assigned appropriate pay percentage

6559 Claim lines where the sum of all payments (total, professional, technical) exceeds the payment expected for the total procedure

6562 New E/M service not allowed for established patient.

6563 Established patient procedure code added to replace new patient procedure code

6566 Procedure rendered more than one time on same date of service

6567 Line added to cutback services to one per day

6570 Claim line contains procedure codes that have exceeded the maximum number of times allowed on a single date of service

6571 Line added to cutback services to maximum per day

6574 Certain laboratory procedure codes associated with diagnoses where the laboratory procedure is not considered medically necessary or payable

6575 Certain laboratory procedure codes that contain diagnoses for which the laboratory procedure is not considered medically necessary or payable

6576 Procedure codes paired with specific diagnoses for which that code pair is defined as covered or payable

6577 Procedure codes paired with specific diagnoses for which that code pair is defined as non-covered or not payable

6578 Procedure codes associated with diagnoses where the procedure is not considered medically necessary, payable, or has payment constraints

6594 CXT Application Error

6595 Enterprise sent the request and no response received for a stipulated time frame.

6596 McKesson detects application error and responds with error code. Error code = 217 through 224 or 20001 through 200102

6597 McKesson detects data error and responds with error code. Error code = 1536 through 1549

6598 McKesson detects fatal error and responds with error code. Error code = 100 through 216 or 256 through 1311

6599 Claim was processed by ClaimsXten

6600 Exact duplicate

6602 Possible duplicate

6604 Possible Conflict/different Provider

6606 Home Infusion Therapy cannot be billed with concurrent care

6608 Duplicate Bilateral Surgery

6610 Inpatient or Nursing home claim vs. Personal Care Services - duplicate

6614 Waiver Service Allowed Same DOS as Institutional Care - duplicate

6616 Pay duplicate of PHN screening to EPSDT screener

31 of 35

Rev. 4/9/2019

Code Description

6618 Inpatient vs all other services - duplicate edit for possible recoupment of non inpatient claim

6620 HIT - Exact duplicate

6622 HIT - Possible duplicate

6624 HIT - Poss Conflict

6626 Duplicate Services for nurshing home

6650 Outpatient claim is a duplicate of a previously paid outpatient claim based on provider, member and DOS.

6700 Daily Respite amount met

6701 Charges exceed Respite daily amount

6702 Aggregate Limit of Individual, Group, and Family Therapy Yearly Service Limit Met

6703 Aggregate Limit of Individual, Group, and Family Therapy Yearly Service Limit Exceeded

6704 Crisis Intervention Yearly Service Limit Met

6705 Crisis Intervention Yearly Service Limit Exceeded

6706 Adult Dental Annual Benefit Met

6707 Adult Dental Annual Benefit Exceeded

6708 Service Limit Met

6709 Service Limit Exceeded

6710 Eye Glass Service Limit Met

6711 Eye Glass Service Limit Exceeded

6712 Benefit Limit Met

6713 Benefit Limit Exceeded

6714 Drug Code LMT 12 Per year Met

6715 Drug code LMT 12 per year exceeded

6716 Hearing Aid Battery Limit Met

6717 Hearing Aid Battery Limit Exceeded

6990 The benefit limit unit of measure code does not equal the claim line item unit of measure code.

7800 UR Limit Met

7801 Observation BH hold limit met

7802 PREGNANCY TEST LIMIT MET

7803 WEEKLY HEMODIALYSIS LIMIT MET

7810 Only 1 Waiver Screenings allowed per 365 days for non-waiver eligible

7811 1 Assessment allowed per calendar year

7812 1 Plan of Care allowed per 365 days

7813 1 Ongoing Care per calendar month

7814 Lifetime Dental Limit

7815 1 per day

7816 Lifetime Limit

7817 Case Mgmt Limit

7818 Physician Visit SNF/ICF Exceeded

7819 Denture Replacement Limit

7820 Denture adjustment limit exceeded

32 of 35

Rev. 4/9/2019

Code Description

7821 Sedative Treatment Limit

7822 PCA Svcs Exceeded

7823 Delivery within 1 year

7824 Therapeutic Leave Days Exceeded

7825 Rental Months exceeded

7826 Auditory Rehab exceeded

7827 Tobacco cessation limit exceeded

7828 Lifetime Limit Genetic Testing

7829 Denture rebase or reline limit exceeded

7831 Two Meals per day Limit exceeded

7838 Chore Svc - Waiver Limit exceeded

7839 Chore Svc WVCCMC Limit exceeded

7840 Fluoride Treatment 2010 Limit Exceeded

7841 Fluoride Varnish Limit Exceeded

7842 Medicament Application Limit Exceeded

7844 Dental Exams Limit Exceeded

7845 Two Prophylaxis per Year

7847 Hearing Aid Battery Monthly Limit Exceeded

7848 Hearing Aid Battery Yearly Limit Exceeded

7849 Cochlear Alk Battery Mthly Limit

7850 One Visual Exam Yearly

7851 Chiropractic Manipulation Services exceeded for year

7852 Cochlear Zinc Batt Mnthly Limit

7853 Observation > 24hrs

7856 Crisis Intervention Daily Service Limit Exceeded

7857 Chore Svc WVMRDD Limit

7858 Lifetime Orthodontia Limit

7859 Adult Denture Exceeded

7860 Adult Half Day Limit

7861 Adult Day code limit

7862 Waiver Screening Limit exceeds 1 per year

7863 TEFRA Plan of Care Limit Exceeds 1 per year

7864 3 months per lifetime exceeded for Supported Employment Services

7865 15 hrs per week day habilitation services

7866 18 hrs per day supported living habilitation services

7867 TEFRA Service Reassessment Limit Exceeded

7868 POC Development over allowed

7869 Ongoing Care over allowed

7870 Drug screen lmt excd: Presumptive

7871 Drug screen lmt excd: Definitive

7872 BEHAVIORAL ID ASSESSMENT Limit Exceed

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7873 BEHAVIORAL ID ASSESSMENT MOD Limit Exceed

7874 ADAPTIVE and GROUP BEHAVIOR TREATMENT Limit Exceed

7875 BEHAVIOR TREATMENT MODIFIED and ADDL Limit Exceed

7876 FAM BEHAV TREATMENT GUIDANCE Limit Exceed

7877 Waiver Screening CFC

7878 Observation BH hold limit exceeded

7879 Newborn Metabolic screening panel lifetime limit exceeded.

7880 PREGNANCY TEST LIMIT EXCEEDED

7881 Weekly Hemodialysis Limit Exceeded

7990 The UR unit of measure code does not equal the claim line item unit of measure code.

8010 The result of the Reimbursement Amount Calculation (Allowed Charge - Co-Pay - TPL Amount - Patient Liability - SA Amount - UR Amount) is Negative.

8020 The Reimbursement Unit Calculation is Negative.

8030 The Claim Amount has exceeded the Service Authorization Approved Amount.

8035 The Claim Amount has met the Service Authorization Approved Amount and Claim has been Cutback.

8040 The Number of Units on the Claim have exceeded the Service Authorization Approved Number of Units.

8045 The Number of Units on the Claim have met the Service Authorization Approved Number of Units and Claim has been Cutback.

8050 The Service Auth unit of measure code does not equal the claim line item unit of measure code.

8070 Member expired prior to LDOS

8080 Member discharge during DOS

8090 Continuous Dates of Service For Interim Billing Required

8095 No paid claim in history with attachment code '30'. If there is no paid or to-be-paid ESRD claim in history for the same member with an attachment code of '30' (Valid 1st ESRD treatment paperwork provided) post this exception. Recycle if claim less than recycle days parameter (21 days)

8096 No paid claim in history with attachment code '30'. If there is no paid or to-be-paid ESRD claim in history for the same member with an attachment code of '30' (Valid 1st ESRD treatment paperwork provided) post this exception. Deny if claim past recycle days parameter (21 days)

8097 ESRD claims for dates of service greater than the 3rd month after first treatment date and there is no entry in the Mcare span to indicate the member is ineligible for Part B Medicare

8900 Adult Day Services vs. Other Svcs

8901 Respite Care Hourly vs. Daily

8902 Residential Supported Living vs. Other Svcs

8903 Family Habilitation vs. Other Waiver

8904 InHome Habilitation vs. Personal Care

8905 Extractions vs. Other Dental

8906 Other Dental vs. Extraction / Root Canal

8908 One Amalgam/Restore per tooth

8909 Anesthesia/PostOp vs. Surgery

8910 Dentures vs. Adjustments

8911 Restoration vs. Components

8913 Lab Components vs. Complete Blood Count

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8914 Complete Blood Count vs. Component Tests

8915 Postpartum Care not allowed more than 60 days after delivery

8916 Postpartum Care is allowed for 60 days after delivery to bypass posting 8915

8917 Home Infusion Therapy

8918 FESC included with G9140

8919 FESC all-inclusive vs. G9140

8920 Respite Hourly vs. Other waiver svcs

8921 Respite Daily vs. Other waiver svcs

8922 Day Habilitation vs. Resid Habilitation

8923 Resid Habilitation vs. Day Hab/Respite

8924 Supported Employment Development Services vs. Supported Employment Ongoing Services/Respite

8925 Supported Employment Ongoing Services/Respite vs. Supported Employment Development Services /Respite

8926 ALH/RSL and Hab services not allowed on same or overlapping DOS

8927 HAB and ALH/RSL services not allowed on same or overlapping DOS

8928 Integrated vs Individual Intake Assessment

8929 Individual vs Integrated Intake Assessment

8930 Residential Habilitation not on same DOS

8931 Dialysis rev code limit 1 per day

8932 Group Home and Trans procs not on same day

8933 Trans and Group Home procs not on same day

8934 Behavior Management vs Anesthesia services

8935 Anesthesia Services vs Behavior Management

8936 Autism service vs other Autism service

8937 Autism service vs Behavioral rehab service

8938 Member vs Escort Accommodations

8939 Amalgam Restoration has been paid for DOS

8940 Anterior Resin Composite has been paid for DOS

8941 Posterior Resin Composite has been paid for DOS

8942 Other Restorative svc vs Protective

8943 BRCA Lifetime Max

9050 Number of exceptions posted on claim exceeds parameter C4-5028

9090 No Fund Code assigned for To Be Paid Claim

9095 No Fund Code assigned for To Be Denied Claim

9098 The fund code that was posted to the claim does not have a corresponding budget record that is effective for the claims adjudication date

9379 System information not found

9512 Member under age 21 when consent form signed

9517 More than 180 days between signature on consent form and service

9527 Insufficient Medical Necessity Justification

9528 Written Explanation of unlisted procedure not sufficient for approval

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9532 Per your request, this claim is being denied.

9558 Consent form does not meet State guidlines

9562 Consent form must be signed by Member

9563 Consent form must be signed by Physician

9564 Consent form must be signed in obtainer’s own handwriting

9565 Consent form must be signed by witness

9566 Alternative paragraph on consent form must be marked as instructed

9567 Minimum of 30 days between sterilization consent sign and surgery not met

9568 Physician’s statement incomplete

9570 Incorrect Date of Birth- Sterilization Related

9572 Members Date of Birth missing on sterilization consent form

9573 Surgery date on claim different from surgery date on consent form

9574 Member statement incomplete

9584 Unit of Measure of Quantity format invalid

9590 The Procedure/Modifier Combination Pricing segment is not covered on the claim for the dates of service

9591 Dental Anesthesia requires primary code billed first.

9592 Provider not eligible to be paid for this service on DOS.

9854 The Mass Adjustment claim is being processed for the first time.

9860 History only adjustment reimbursement amount is greater than the reimbursement amount on the claim being adjusted.

Documents

Alaska Medicaid MMIS Claim Exception Codesmanuals.medicaidalaska.com/docs/dnld/Update...1 of 35 Rev. 4/9/2019 Alaska Medicaid MMIS Claim Exception Codes Code Description 0004 The member