Adjustment Code Descriptions as of 10/30/09
Gateway Health Plan^® Provider Distribution – Medicaid

• Rejection/Denial Codes
• Remark Codes
• Adjusted/Appealed/Corrected Codes
• Claim Line Changes

Rejection/Denial Codes

D1 - Rejected - MedicalRecords
The patient’s medical records arerequested in order to review the claims for payment. Often this remark is used when considering the emergency room treatment or to determine discrepancies between procedure and diagnosis codes or levels of treatment provided.

D2 - Denied - Not the Member’s Capitated Provider
Payment will not be issued for this service, as capitation has already been paid to another provider for this service and should have been performed by that provider.

D3 - Rejected - Age Discrepancy with Procedure Code Billed; Refile
The procedure code submitted is not appropriate based on the age of the member.

D4 - Rejected - Invalid Modifier OR Invalid Modifier/Procedure Code Combination; Refile
Submit appropriate CPT-4 modifiers with CPT codes and HCPCS modifiers with HCPCS codes. Invalid modifier, modifiers attached to a code that result in $0 payment and procedure code combinations are not covered. Providers should submit appropriate modifiers even if they do not affect payment of the claim. The inappropriate use of modifiers may generate audits or denials.

D5 - Rejected - Invalid Procedure Code; Refile within the Follow Up Time Period
Valid procedure codes for Gateway are those codes which are listed on the fee schedule for the most current update or approved by Gateway. The codes include currently active CPT-4 codes, or HCPCS codes. Inappropriate use of codes may generate audits or denials.

D6 - Rejected - Itemized Bill with Dates of Service Required; Refile
Multiple dates of services must be itemized on the UB-04 or CMS-1500 form to list all specific procedure codes performed and the dates on which each procedure was performed.

D7 - Rejected - Diagnosis Invalid, Invalid for Date of Service or Not Consistent with Procedures Billed
Currently active ICD-9 diagnosis codes are required on all claims, and if additional digits are required beyond the first 3 numbers designating the diagnosis code, those must be placed on the claim, as well. All claims without a valid diagnosis code will be denied for this reason.

D8 - Rejected - Expenses Incurred After Coverage Terminated
(Please see D63 for denial if expenses incurred prior to enrollment)
According to the eligibility information available on the day the claim was processed, this patient was not enrolled with Gateway Health Plan^® on the date of service. Claim payment is contingent upon eligibility on the date of service, regardless if there was an authorization given prior to the service. Eligibility can be verified with Gateway Health Plan^® 24 hours a day, 7 days a week. Refer to the Eligibility section of the Policy and Procedure manual for more details.

D9 - Denied - Benefits Terminated for Date of Service
Benefits for the services billed were not allowed due to a medical necessity or a level of care discrepancy. Discussions have already taken place between Gateway Health Plan^® Utilization Management Department and the provider of service about this treatment. Requests for review of this denial should be directed to the Appeals Department. Refer to the Appeals and Grievance section of the Policy and Procedure manual for more details.

D10 - Rejected - Exceeds Maximum Filing Time Limit
365 days from the date of service is allowed for initial claim submissions. All claims are inventory controlled and date-stamped the day they are received in the Gateway claims processing office. A claim will only be accepted as filed if it is received within 365 days from the date of service.

D11 - Rejected - Resubmit with EOB from Primary Carrier to Include Reason for Denial
Based on existing insurance information, the member who received the services provided has other primary insurance. The claim must be processed by a primary carrier before submission to Gateway. The provider should refile the claim with an explanation of benefits (EOB) from the primary carrier in order for Gateway Health Plan^® to consider payment.

D12 - Denied - Motor Vehicle Accident - Auto Insurer is Primary/EOB
The claim is related to a motor vehicle accident for which another carrier or party may be liable. A letter from the auto carrier as proof of no insurance will be accepted or an EOB must be submitted. Provider cooperation will be required to obtain necessary information so that claims can be settled as quickly as possible.

D13 - Denied - Worker’s Compensation is Primary Carrier/EOB
Based on information provided on the claim, the claim should be filed with the member’s Worker’s Compensation insurance company. A letter from the Worker’s Compensation carrier documenting denial or exhaustion of benefits will be accepted or an EOB must be submitted.

D14 - Rejected – Claim and EOB Must Match
A bill for a particular service was sent in and the EOB attached to it does not indicate a payment or denial for the service that is submitted to Gateway (the EOB appears to be for another service provided that is not on the bill).

D15 - Keystone Health Plan West is Carrier for this Service
This code is not applicable for services rendered on or after 5/1/98.

D16 - Rejected - Davis Vision is Carrier for this Service
By contractual agreement, routine refractive services, glasses, and contacts are covered for Gateway members by another carrier. Claims and all related documentation must be handled by this carrier. Refer to the Benefits section of the Policy and Procedure manual for specific mailing instructions and further details.

D17 - Rejected Argus Healthcare is the Pharmacy Carrier Responsible for this Service
By contractual agreement, most legend and non-legend (OTC) drugs under the formulary for Gateway members are covered by another carrier. Claims and all related documentation must be handled by this carrier. Please refer to the Benefits section of the Policy and Procedure manual for specific mailing instructions and further details.

D18 - Denied - Other Services Included with Payment of Primary Services
Supplies or services are considered included in the total charges of an inpatient admission. This code may also be used for office services or for any applicable payment circumstances.

D19 - Denied - This Procedure Code is not Compensable under Medicaid/Medical Assistance/Medicare or Gateway
Gateway does not issue payment for procedure codes that are not compensable under Medicaid/Medical Assistance/Medicare or Gateway.

D20 - Denied - Over Max Procedure/Limit
The service(s) provided exceeds the maximum allowable number of services available in this period for this member under Gateway Health Plan^®.

D21 - Rejected - No Referral/Invalid/Expired
A member’s Primary Care Physician determines the need for a Gateway member to receive medical services from a specialist, facility, or ancillary provider; and the PCP must write a Referral Form for these services. Written or electronic referrals are good for a maximum of three visits^* or 90 days (whichever is first) for medical care and 3 days for Emergency Room Services. The referral must be dated on or prior to the date of service by a specialist, facility, or ancillary provider. A few self-referral situations do exist. See the Referrals and Authorization section of the Policy and Procedure manual for more details. (^*Please refer to the Referral Form for specific criteria pertaining to certain services not limited to 3 visits).

D22 - Rejected - No Valid Precert on File (Wording change 7/20/09)
D22 will be used for denying precerts that are missing, invalid or expired. Certain services require precertification (authorization) from Gateway Health Plan^® Utilization Management Department. A provider must call the UM Department at Gateway on the day of or before a service takes place to receive a review of medical appropriateness for the service. If a precertification is issued, it is time and procedure specific and will expire. Please confirm the precertification with the UM Department. Retrospective precertification will not be given.

D23 - Denied - Same Service Paid to a Different Provider OR Billing Provider Ineligible to Submit Charges
Another provider billed for the same procedure or service under the same circumstances on the same day and was reimbursed. It is not Gateway Health Plan^® policy to reimburse twice for the same procedure unless plan criteria allows payment. Also, bills received from providers who are not eligible for reimbursement will be denied (eg Physician Assistants).

D24 - Rejected - Related Maternity Claim Not Received
A combined inpatient per diem is paid for the mother and baby (provided both are discharged on the same day and are not placed in any special unit or bed for care) is issued to a hospital for obstetrical delivery admissions. When bills are submitted separately for the mother and baby, payment determinations are made in accordance with pre-certification allowances.

D25 - Denied - Duplicate Claim - Paid/Denied Previously
This claim was previously processed and a payment or denial was issued. The payment/denial was found to be appropriate and no further consideration will be given without the submission of information to offset a denial, prove an incorrect payment amount, or file an appeal/grievance. All appeals/grievances should be directed to the Appeals Department. Refer to the Appeals and Grievance section of the Policy and Procedure manual for more details.

D26 - Duplicate Claim - Original Claim Under Review
This service or claim has been acknowledged as received by Gateway Health Plan^®; however, either a duplicate submission during the same payment period or technical system constraint, such as a fee or code in development or waiting to be added to the system has caused processing to be delayed.

D27 - Submit Bill to Medical Assistance Fee-For-Service
The State Medical Assistance Program accepts financial responsibility for this type of medical service or the specific member on the claim.

D28 - Denied - EPSDT Form Is Incomplete
(Not Applicable for EPSDT Services Reported on MA 517 Form for dates of service 10/1/01-2/29/04)
The EPSDT Form is completed in conjunction with required testing based on a member’s age as outlined by the periodicity table. If a required test was not reported on the form, payment for the EPSDT screen is denied.

D29 - Emergency Room Visit Not Approved
The service(s) provided in the Emergency Room setting were not approved. Medical documentation has been reviewed by a utilization review nurse and the Gateway Health Plan^® (GHP) Physician Advisor. The GHP Physician Advisor makes the final determination of payment or denial.

D30 - Denied - Additional Information Needed to Support Payment (Description of Code changed on 3/1/04)
This code is used when a required form or appropriate codes for OB intake/1st trimester bonus OR appropriate codes for EPSDT reimbursement were not submitted in accordance with plan criteria. A bill for an Obstetrical Intake Package requires a Prenatal Risk Assessment Form to be in Gateway’s records; billing for Intake (T1001-U9) and 1st trimester bonus (99429-HD) must be on same claim for reimbursement. EPSDT reimbursement will not be allowed unless code S0302 and an appropriate 993XX preventive medicine evaluation and management code are both submitted.

D31 - Rejected - EPSDT Form Not Submitted (applicable to dates of service prior to 1/1/02)
This code is discontinued.

D32 - Denied - Prior Payments Equal DME Purchase Amount
A DME item can be rented from a provider for a Gateway member. If it is rented, payments will only be made until the purchase price is reached.

D33 - Rejected - Charges OR Units Not Submitted on Bill
The provider did not submit a charge for a billed procedure code or units required on a UB-04; therefore, Gateway is unable to issue any payment since the provider did not indicate charges OR number of units being billed on a UB-04.

D34 - Itemize Payments by Procedure Code on the EOB
If Gateway Health Plan^® is secondary to a member’s primary medical insurance, Gateway is required to consider payment as payer of last resort to the provider of service. When the EOB is sent to Gateway, each procedure code processed must be associated with some portion of the charges on the EOB or the claims system cannot determine a correct payment. Therefore, further detail is requested from the primary insurer. Itemized statements are not required for Extended Nursing Care services as long as the dates of service on the EOB correspond to the dates on the bill.

D35 - DO NOT USE CODE AS OF 7/20/09
Rejected – Submitted Bill Does Not Match Authorization

D36 - Rejected - Discrepancy in Level of Care with Authorization
When the Utilization Management Department issues an Authorization for a service or procedure, the level of care provided must be defined. For example, an inpatient stay will have a bed defined (i.e., a pediatric bed in a semi-private room). If the bill submitted by the provider indicates a discrepancy in the care rendered versus what was actually precertified, then the claim is denied for this reason.

D37 - Rejected - Must Use Contracted and/or Authorized Procedure Code(s) for Ambulance/Transport Services
All ambulance/transport providers are required to bill Gateway with procedure codes that are contracted and/or authorized for reimbursement.

D38 - Baby Not Enrolled in Plan; Refile with the Baby’s Gateway ID Number
A baby is not added to Gateway Health Plan^® until the mother’s caseworker or the State is notified of a new enrollment. Then, the baby is assigned a recipient number and can be enrolled in Gateway Health Plan^® (retroactive to the date of birth). All claims are processed under the individual recipient in Gateway’s claims system.

D39 - Rejected - Refile with Gateway Member ID Number
Member information is incorrect/incomplete and we can not identify the Gateway Health Plan^® member. Please resubmit claim with correct information.

D40 - Denied – Anesthesia Minutes Reported Incorrectly; Resubmit In Quantity Field
Anesthesia claims processing requires providers billing with codes 00100-01999 to identify time units in whole minutes in area 24G of the CMS-1500 form (formerly HCFA) for proper reimbursement. If time is not indicated or listed in another area of the form, appropriate payment cannot be determined. Please resubmit.

D41 - DO NOT USE - Informal Review Denial
This code is discontinued.

D42 - DO NOT USE - Non-Par Informal Review Denial
This code is discontinued.

D43 - Resubmit Claim to Dental Carrier
By contractual agreement, dental services are covered for Gateway members by another carrier. Claims and all related documentation must be submitted directly to this carrier. Refer to the Benefits section of the Policy and Procedure manual for more details.

D44 - Submit Claim to Behavioral Health Provider
Behavioral Health services for members are limited to Emergency Room services that do not result in an in-patient admission. Please resubmit claim to correct payer.

D45 - Medical Services Not Approved Per Claims Administration OR Medical Review
The services provided for medical care were not approved. Medical documentation has been reviewed by claims administration, a utilization review nurse or the Gateway Health Plan^® (GHP) Physician Advisor (for other than administrative level reviews).

D46 - Medical Records Are Insufficient
This code indicates that documentation was received, but the medical records received are not sufficient to render a decision (illegible notes, insufficient documentation of symptoms, etc.).

D47 - Rejected- Provider ID or NPI Number And Tax ID Number Do Not Match
This code is used when the claim cannot be processed since the provider number or NPI number and the tax identification number do not match information contained in Gateway’s records. Please submit documentation to allow records to be updated.

D48 - Denied - Diagnosis not consistent with Medical Review
This code is used when a review of medical records has been conducted, and the findings in the records are used to reverse a previously paid claim. Final determination of claim payment is based on the results of the medical records.

D50 - Denied for Multiple Reasons
This code is discontinued.

D51 - Denied - Services Billed Under Newborn Number
Claim incorrectly billed under newborn ID number.

D52 - Denied - Services Not Paid Until Confinement Ends
Payment of charges applicable to DRG reimbursement is not issued until discharge diagnosis submitted.

D53 - Lab Not Authorized or Performed by Non-Capitated Provider
This code is used when lab services are rendered by a provider other than the member’s capitated lab provider. Additionally, if a member does not have a capitated lab provider, the code is used to designate that a referral/auth has not been obtained.

D54 - Deny - No Referral after 1st/2nd Review
This code is used for special project purposes to identify if referrals are submitted after the claim is received for payment.

D55 - Claims Combined for Editing
Claims finalized by the claims processor but not yet updated in the claims system through the A/P process are denied if charges on a new claim result in a coding edit applicable to both claims. The original claim is denied and all services are processed on a single claim.

D56 - Professional Fees Must Be Billed With A Modifier
Charges that require modifiers to allow appropriate reimbursement will be rejected to alert providers of correct billing procedures.

D57 - Rejected – DRG Code Required
Inpatient claims that require a DRG code for payment determination will be rejected if the DRG code is not included on the claim.

D58 - Deny – Administrative This code should be used only for claims resulting from denied authorizations by NIA for CT Scans/MRI services.

D59 - Retrodisenrollment – Submit to Medical Assistance
Claims that are adjusted due to delayed notification of a disenrollment received by Gateway Health Plan^® will be reprocessed and denied with this code.

D60 - Submit NDC Code, Name, Dosage, Quantity OR Verify Quantity of Billed Code
Charges that are eligible for payment under the medical plan need to be submitted with one of the following codes: J3490, J7599, J7799, J8499, J8999, J9999 or 90799 along with NDC code, drug name, dosage and quantity to be processed. Claims submitted with an unclassified J code and NDC that appear to include an incorrect quantity will be denied for provider review of NDC and/or quantity.

D61 - Procedures For Billing W/Group, Referring, Performing Provider Were Not Followed
(Code will be used with Management Approval Only)
This code is discontinued.

D62 - Rejected - Sex Discrepancy with Procedure Code Billed; Refile
(New code eff 8/12/03 – see D3 for Age Discrepancy note)
The procedure code submitted is not appropriate based on the sex of the member

D63 - Rejected - Expenses Incurred Prior To Coverage
(New code eff 8/12/03 – see D8 for denial if expenses incurred after coverage terminated)
According to the eligibility information available on the day the claim was processed, this patient was not enrolled with Gateway Health Plan^® on the date of service. Claim payment is contingent upon eligibility on the date of service, regardless if there was an authorization given prior to the service. Eligibility can be verified with Gateway Health Plan^® 24 hours a day, 7 days a week. Refer to the Eligibility section of the Policy and Procedure manual for more details.

D64 - Rejected – Services Must be Billed on a HCFA or UB Form
EPSDT services billed on an MA-517 form for dates of services on or after 3/1/04 will be denied with this code to convey that only CMS-1500 form (formerly HCFA) or UB forms are acceptable. Other services billed on non-standard forms will also be denied with this code.

D65 - Denied – Paper UB-04 Forms Cannot be Processed Unless a Valid Type of Bill is Submitted in Field 4; Resubmit
The Type of Bill is required on UB forms for claims processing purposes. Electronic Claims will be rejected by the clearinghouse and paper claims will be rejected through the claims system.

D66 - Denied – Claim Does Not Have ANY Diagnosis Code(s) on the Bill. One or More Valid Diagnosis Code(s) Required; Resubmit
Claims submitted without any diagnosis codes cannot be processed. Every bill must have a minimum of one diagnosis code submitted or it will be denied with code D66. Claims submitted with invalid diagnosis code(s) for the date of service will result in a claim denial under a different adjustment code.

D67 - Denied – Infertility Services are not Covered by Medical Assistance or Gateway
Claim lines submitted with a diagnosis code or for a service for infertility are not eligible for reimbursement by Gateway Health Plan^®.

D68 - Denied – Renal Dialysis Services are not a part of your Benefit Package under MA or Gateway
Renal Dialysis services submitted for members who do not have the Renal Benefit are not eligible for reimbursement by Gateway Health Plan^®.

D69-D73 - Codes Not Applicable to PA Medicaid

D74 - XRAY'S Performed by a Chiropractor are not Reimbursable
The medical plan does not allow xray’s performed by a Chiropractor.

D75-D79 - Codes Not Applicable to PA Medicaid

D80 - Our Records Show the Date of Service was after the Date of Death

D81-D90 - Codes Not Applicable to PA Medicaid

D91 - Procedure Code/Bill Type Not Consistent with the Place of Service Code
This code will be used when a ‘required’ place of service code is not submitted on the claim.

D92 - Code Not Applicable to PA Medicaid

D93 - Denied – Experimental or Investigational Procedure or Service
Gateway will not cover or reimburse services determined to be experimental or investigational. Experimental or investigational services are not covered by Medicaid.

D94-D96 - Codes Not Applicable to PA Medicaid

D97 - Missing or Invalid Present on Admit Indicator. Resubmit with a Valid Present on Admit Indicator on all Principal and Secondary Diagnosis Codes.
Every diagnosis code must include a valid POA indicator in fields 67A-Q and 72 A-C or the claim must be denied, per processing rules. Valid indicators are: Y, N, U, W, 1.

D98 - Rejected – Depending on Services Rendered, Authorization from NIA or Family Health Council is Missing, Invalid or Expired
This code designates that the required auth for NIA or Family Health Council was not found or valid for the codes or dates of services billed.

D99 - Rejected – Resubmit with Individual Rendering Provider Information
Claims submitted on a CMS 1500 form or electronically must include an individual provider in Box 31 of the paper form and in the appropriate field of an electronically submitted claim.

D100 - Denied – System Generated Duplicate Claim/Service Previously Paid
Gateway system procedure identified duplicate claims service(s).

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RemarkCodes

R1 - Capitated Service
No payment will be issued for this service as capitation has already been paid to the provider of service.

R2 - Payment Reflects Non-Medicare COB
The primary insurance carrier’s payment was included in the Gateway Health Plan^® calculation. Payment allowed represents Gateway’s contracted liability less the primary carrier’s payment (based on approved/contracted amount) for the service(s).

R3 - Combined Mother & Baby Payment
Payment for this service reflects compensation for both mother and baby charges during an inpatient delivery stay.

R4 - Interim Bill Payment
This payment is recognized to be an interim payment and may be recalculated based on contractual agreement upon receipt of a final bill.

R5 - Contracted/Negotiated Rate
Payment for this service was made at a special contracted or negotiated rate with the provider of service.

R6 - Reprocessed To Allow Corrected Payment Amount
Reprocessing due to reviews and/or projects may use this code to designate that a payment amount has been adjusted.

R7 - Paid at Quantity Allowed in Authorization
When the Utilization Management Department issues an authorization, the quantity of the procedure or service must be defined. In the event the quantity on the bill exceeds the authorization limit, the additional quantities are not allowed.

R8 - Claim Resolution Finalized
This code allows any claim requiring additional investigation to be finalized in accordance with current data included in the claim system.

R9 - Third Party Liability Refund to DPW
This code is used to redirect payment to DPW when Gateway receives a refund from a provider for a TPL expense for which Gateway is obligated to pay.

R10 - Nonclean EDI - Provider/or Member # Not Submitted
Claims processing criteria included incorrect/incomplete information and additional research was required for an electronically received claim.

R11 - Fee/Code Update Completed
This code is applicable to claim adjustments resulting from coding changes and the Remarks code is restricted to usage only by the claim review dept.

R12 - Payment Represents Interest Amount
This code is used to identify claims paid with interest on a remittance advice due to investigation of a delayed payment.

R13 - Payment Reflects Medicare COB
This claim reflects coordination of benefits with Medicare as the primary carrier. Gateway determines its cost-sharing liability by calculating the difference between the Gateway contracted rate and the amount Medicare pays (including adjustments for Medicare approved amounts and contractual allowances).

R14 - EPSDT Processed After MA ID Research (Code discontinued for dates of service of 3/1/04 or after)
Claims submitted by providers on MA 517 EPSDT forms (effective 10/1/01 – 2/29/04) that do not have a cross reference to an MA ID number in Gateway’s records will be researched and Gateway’s provider record will be updated. The claim will be processed after the update is completed.

R15 - Amount Paid Represents EPSDT Reimbursement Rate (Applicable for Dates of Service of 3/1/04 or later)
Payment for claims processed for EPSDT services will reflect the provider’s contracted rate for code S0302 when billed along with the appropriate 993XX preventive medicine evaluation and management code.

R16 - Adjustment to Previously Processed Claim Due to Special Claims Project
This code will be used to denote special processing or bulk adjustment projects.

R20 - Invalid Place Of Service – Code May Have Been Corrected To Allow Payment
CMS-1500 Place of Service codes are used by Gateway to process claims. This notification is to make you aware that the code on the claim was incorrect. If payment was not affected by the erroneous place of service code, it was not changed. If payment was affected by the erroneous place of service code, it was changed to allow proper reimbursement. Please review place of service codes and utilize CMS-1500 codes for claims submissions to Gateway.

R21 - Inactive Healthy Beginnings Provider Number Billed. Use of this Number ended 5/15/07. You must Bill with your Original Provider Number on Future Claims Submissions
Due to a system change in 2007, Gateway eliminated a second provider ID number for providers rendering Healthy Beginnings services. Payment is allowed at $0 under inactivated number. All claims are paid under original provider number and noted with code R21 to educate providers of the correct billing ID.

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Adjusted/Appealed/Corrected Codes

A1 - Adjustment to Recover Previous Payment
Additional payment has been approved for this service OR the service was over-paid OR is a duplicate payment and money has been subtracted to correct the error.

A2 - Administrative/Medical Adjustment
Payment for this claim has been allowed outside normal processing guidelines. Although the service may not have had approval from the PCP or Gateway Health Plan^®, the situation is one where medical attention was warranted OR where payment is deemed appropriate by administrative personnel of Gateway Health Plan^®.

A3 - Appeal/Grievance - Denial Overturned
This service has been reconsidered as a result of an appeal by the provider and the original decision to deny the service/claim has been overturned.

A4 - Appeal/Grievance - Denial Upheld
This service has been reconsidered as a result of an appeal by the provider and the original decision to deny the service/claim has been upheld.

A5 - Appeal/Grievance - Payment Upheld
This service has been reconsidered as a result of an appeal by the provider and the original decision to pay this claim has been upheld. The original payment is considered to be a final and complete payment.

A6 - Claim Processing Error - Corrected
This is a claim correction due to a data keying error of information provided on a claim form that was made by a Gateway Health Plan^® claims processor.

A7 - Incorrect Quantity - Claim Corrected
This is a claim correction as a result of an error in keying the correct quantity of a procedure or in overlooking additional claim documentation referencing the quantity of service provided.

A8 - Emergent Diagnosis
This claim has been processed for payment because any of the diagnoses submitted for the emergency room services allow the claim to be paid.

A9 - Authorized Emergency Room Visit
This claim has been processed for payment because the provider received approval for an emergency room visit from either the member’s PCP or from Gateway’s Utilization Management Department.

A10 - Authorized Liability
The original liability on an authorization was changed to allow a claim to be attached to the authorization and paid. A10 is used only for internal purposes at Gateway and will not appear on a remittance advice.

A11 - Additional Forms Received; Claim Reprocessed
The claim is now eligible to be processed correctly, because additional forms were received from the provider (i.e., an itemized bill, an invoice, etc.).

A12 - DO NOT USE - Appeal Denied; Medical Records are Insufficient
This code is discontinued.

A13 - DO NOT USE - Appeal Denied; ER Criteria Not Met
This code is discontinued.

A14 - Check Returned/Refund; Claim Reprocessed
This adjustment code is used to indicate the reprocessing of a claim that has been associated with a returned or refunded check submitted by the provider.

A15 - Referral Found after Additional Review
This code is used for special project purposes to identify if referrals are submitted after the claim is received for payment.

A16 - Claim Reversed for Editing
This code is used to reverse a service previously submitted and processed when a charge on a new claim results in a coding edit applicable to both services - the original claim is reversed and all services are processed on the current claim.

A17 - See Member ID# - Please Update Records
Claims that are received electronically with incorrect Gateway member ID# are reviewed to attempt to process the claim the first time it is received. If the claim is processed, this note notifies the provider that information in their records needs to be updated/corrected.

A18 - Adjustment – Reflects Cost Outlier Payment
(Please note wording changed on 8/12/03 – see A20 for Day Outlier note)
Gateway proactively reviews recent claim payment activity to identify if an outlier payment is due to a participating DRG hospital facility. Claims that are assigned this code reflect additional payment made as a result of cost outlier criteria.

A19 - Adjustment – Reflects Hospital Readmission
Gateway complies with criteria for readmissions due to a prior hospital admission. With limited exceptions, claims for readmissions to the same facility with 7 days are combined and all dates of services are considered as the same period of hospital confinement.

A20 - Adjustment – Reflects Day Outlier Payment
(New code eff 8/12/03 – see A18 for Cost Outlier note)
Gateway proactively reviews recent claim payment activity to identify if an outlier payment is due to a participating DRG hospital facility. Claims that are assigned this code reflect additional payment made as a result of day outlier criteria.

A21 - Adjustment – DRG Payment Due to Hospital Transfer
Gateway complies with criteria for hospital transfers from one DRG reimbursed facility to another. Hospital charges for the facility transferring the patient are allowed at a prorated DRG amount for each day of approved care. Circumstances that apply to the discharge facility being allowed a prorated DRG amount are also evaluated and processed accordingly.

A22 - Adjusted – See Corrected Member ID Number on EOB. Please Update Your Records
When a claim for a member enrolled in a Gateway plan other than the one the paper or electronic claim was submitted to, claims are processed under the correct line of business and this note is added. Providers are to amend their records and submit all subsequent claims to the correct PO Box or Electronic Payer ID # to ensure prompt payment.

A23 - Payment Adjusted because Charges have been Paid by Another Payer
This code should be used when claims are reversed and will be adjusted due to an insurance payment from a primary insurance plan.

A24 - Adjustment to Member Accumulator
This code identifies the reason for the adjustment.

A25 - System Edit Indicated Potential Duplicate; However, After Review Duplicate Not Found
Code represents resolution of reviews for possible duplicate claims services.

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Claim Line Changes

C17 – Procedure Code Replaced or Rebundled
This adjustment code is a generic code to identify any claim line that has been replaced or rebundled to meet plan criteria. The claim line(s) that replace(s) the submitted charges will appear separately on the claim. This code has been instituted to meet HIPAA requirements.

C18 – Default Claim Line Denial
The adjustment code is a generic code to identify any claim line that does not warrant any payment. The claim line(s) that replace(s) the submitted charges will appear separately on the claim. This code has been instituted to meet HIPAA requirements and will most frequently apply to claim lines audited by Gateway’s coding program.