Adjustment Codes
Please Note: Data subject to change in order to comply
with HIPAA Regulations. Gateway will notify practitioners
of changing policies via an update mailing or the Provider
Newsletter, The Gateway Review.
KEY:
D# - Claim Rejection/Denial Code
R# - RemarksCode to Identify a Gateway
Processing/Payment Rule
A# - ClaimAdjusted/Appealed/Corrected
Code
C# - Coding
to identify 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 roomtreatment or
to determine discrepancies between procedure and diagnosis
codesor levels of treatment provided.
D2 - Denied - Not the Member
’sCapitated Provider
Payment will not be issued for thisservice, as capitation
has already been paid to another provider for thisservice
and should have been performed by that provider.
D3 -
Rejected - AgeDiscrepancy Related to the Procedure Code
Billed; Refile
The procedure code submitted is notappropriate based on
the age of the member.
D4 -
Rejected - InvalidModifier OR Invalid Modifier/Procedure
Code Combination; Refile
Submit appropriate CPT-4 modifierswith CPT codes and HCPCS
modifiers with HCPCS codes. Invalid modifier and procedure
code combinations are notcovered. Providers should
submitappropriate modifiers even if they do not affect payment
of the claim. Modifiers solely applicable to MedicalAssistance
pricing are not acceptable for Gateway and may result indenials.
The inappropriate use ofmodifiers may generate audits or
denials.
D5 -
Rejected - Invalid Procedure Code; Refile W/In 90Days
of RA
Valid procedure codes for Gatewayare those codes that are
listed on the Medical Assistance fee schedule for themost
current update or approved by GHP. The codes include currently
activeCPT-4 codes, or HCPCS codes. The inappropriate use
of codes, which may or maynot effect payment, may generate
audits or denials.
D6 -
Rejected - Itemized Bill w/ Dates of Service Required; Refile
Multiple dates of services must be itemized on the UB or
HCFA to listall specific procedure codes performed and the
dates on which each procedure was performed. This
requirement does not apply to Extended Nursing Care
services.
D7 -
Rejected - Invalid Diagnosis Code; Refile W/In 90 Days of
RA
Currently active ICD-9 diagnosiscodes are required on all
claims, and if additional digits are required beyondthe
first 3 numbers designating the diagnosis code, those must
be placed on the claim, as well. All claims without
avalid diagnosis code will be denied for this reason.
D8 -
Rejected - Expenses Incurred After Coverage Terminated
(Please note wording changed on8/12/03 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 a referral or 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 Member Eligibility section
of the Policy and Procedure manual for more details.
D9 -
Denied - Benefits Terminated for the
Date of Service
Benefits for theservices billed were
not allowed due to a medical necessity or a level of carediscrepancy.
Discussions have already taken place between Gateway Health
Plan’s Utilization Management Department andthe provider
of service about this treatment. Appeals of this denial
should be directed to the AppealsDepartment. Refer
to the Complaint andGrievance Section of the Policy and
Procedure manual for more details.
D10 -
Rejected - Exceeds Maximum Claim Filing
Time
180 days from the date of service isallowed for initial
claim submissions, with the exception of EPSDT claims,which
must be filed within 60 days. Allclaims are inventory
controlled and date-stamped the day they are receivedin
the Gateway claims processing office. A claim will only
be accepted as filed if it is received within 180 daysfrom
the date of service, unless it is an EPSDT claim, which
must be filedwithin 60 days from the date of service.
D11 -
Rejected- Resubmit with EOB from Primary Carrier
Based on the existence of other insuranceinformation in
the Gateway Health Plan® claims system or on the documentation supplied
by the Medical Assistance Program, the member who received
the services provided has other primary insurance. The
claim must be processed by a primary carrier before submission
to Gateway. MA Managed Care Plans are thepayers of
last resort and receive information on other insurance directly
from the Department of Public Welfare. If this information
is incorrect, the member will need to contact the County
Assistanc eOffice Case Worker to have the incorrect information
removed from the State’s system. If other primary
insurance has been determined to exist, 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. Any attorney involvement due to personal injury
lawsuit must be reported to the TPL division of the Department
of Public Welfare immediately.
D12 -
Denied- Motor Vehicle Accident - Auto Insurer is Primary/EOB
(DO NOT USE IF ACC ON OR AFTER1/1/99)
The claim is related to a motorvehicle accident for which
another carrier or party may be liable. A notarized
affidavit of no insurance or aletter from the auto carrier
as proof of no insurance will be accepted. However,
Pennsylvania’s law, Act VI, maystill allow for recovery
through any household auto insurance coverage. Provider
cooperation will be required toobtain necessary information
so that claims can be settled as quickly aspossible.
Any attorney involvement dueto personal injury lawsuit must
be reported to the TPL division of theDepartment of Public
Welfare immediately.
D13 -
Denied - Worker’sCompensation is Primary Carrier/EOB
Based on information providedthrough the Department of Public
Welfare or information provided on the claim,the claim should
be filed with the member’s Worker’s Compensation
insurancecompany. A letter from the Worker’sCompensation
carrier documenting denial or exhaustion of benefits will
beaccepted with a refiled claim.
D14 -
Rejected -Provider’s Bill and the EOB Must Correspond
A bill for a particular service wassent in and the EOB attached
to it does not indicate a payment or denial forthe service
that is submitted to Gateway (the EOB appears to be for another
serviceprovided that is not on the bill).
D15 -
KeystoneHealth Plan West is Carrier for this Service
This code is not applicable forservices rendered on or after
5/1/98.
D16 -
Rejected - Davis Visionis Carrier for this Service
(Effective 11/1/04, Clarity is
nolonger the plan administrator for vision claims)
By contractual agreement, routinerefractive services, glasses,
and contacts are covered for Gateway members byanother carrier.
Claims and all related documentation
must be handled by this carrier. Refer to the Member
Benefits section of the Policy and
Procedure Manual for further details.
D17 -
Rejected Argus Healthcare Pharmacy Carrier Responsible for
this Service
By contractual agreement, mostlegend and non-legend (OTC)
drugs under the formulary for Gateway members arecovered
by another carrier. Claims and
all related documentation must be handled by this carrier.
Please refer to the Member Benefits
section of the Policy and Procedure Manual forfurther details.
D18 - Denied
-Other Services Included with Payment of Primary Services
Pre-admission testing and othersupplies or services are
considered included with the total procedure performedin
a facility setting or with the total charges of an inpatient
admission. This code may also be used for officeservices.
D19 -
Denied This Procedure Code is not Compensable under Medical
Assistance or Gateway
Gateway does not issue payment for procedurecodes that at
not compensable under Medical Assistance or Gateway.
D20 -
Denied - Over MaxProcedure/Benefit 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 /Expired/InvalidReferral
A member’s Primary Care Physician determines the need
for a Gateway member to receive medical services from aspecialist,
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 referralmust be dated on or prior to
the date of service by a specialist, facility, orancillary
provider. A fewself-referral situations do exist.
Seethe Referrals and Authorization
Section of the Policy and Procedure Manual for more details.
(*Please refer to the Referral Form forspecific criteria
pertaining to certain services not limited to 3 visits).
D22 -
Rejected - NoPrecert/Expired/Invalid Precertification
Certain services require precertification (authorization)
from Gateway Health Plan’s Utilization Management Department.
A provider mustcall the UM Department at Gateway on the
day of or before a service takes placeto receive a review
of medical appropriateness for the service. If a precertification
is issued, it istime and procedure specific and will expire.
Please confirm the precertification with the UM Department.
Retrospective precertification will not begiven. If
the services rendered were insupport of another provider,
please confer with that provider regarding precertification
obtained. See theReferral and
Authorization Section ofthe Policy
and Procedure Manual for more details.
D23 -
Denied - Same ServicePaid to a Different Provider
Another provider billed for the sameprocedure or service
under the same circumstances on the same day and wasreimbursed.
It is not Gateway HealthPlan’s policy to reimburse
twice for the same procedure; coordination between providersshould
occur.
D24 -
Rejected - RelatedMaternity Claim Not Received
A combined inpatient per diem ispaid for the mother and
baby (provided both are discharged on the same day andare
not placed in any special unit or bed for care) is issued
to a hospital forobstetrical delivery admissions.
Whenbills are submitted separately for the mother and baby,
payment determinationsare made in accordance with pre-certification
allowances.
D25 -
Denied - DuplicateClaim - Paid/Denied Correctly Previously
This claim was previously processedand a payment or denial
was issued. Thepayment/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. All appeals should be directed
to the Appeals Department. Refer to the Complaints
and Grievance Section of the Policy and Procedure Manual
for more details.
D26 -
Duplicate Claim -Original Still Under Consideration
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 charges to the MAFee-For-Service Program
The State Medical Assistance Programaccepts 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 inconjunction with required
testing based on a member’s age as outlined by theperiodicity
table. If a required testwas 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 autilization review nurse and the Gateway
Health Plan (GHP) Physician Advisor. The Gateway Physician
Advisor makes the final determination of payment or denial.
D30 -
Denied Additional Information Needed to Support Payment
(Description of Code changedon 3/1/04)
This code is used to designate thata required form for an
OB Intake Package or appropriate codes for EPSDTreimbursement
were not submitted in accordance with plan criteria.
A bill for an Obstetrical Intake Package(W5950) requires
a Prenatal Risk Assessment Form. EPSDT reimbursement
will not be allowed unless code S0302 and anappropriate
993XX preventive medicine evaluation and management code
are bothsubmitted.
D31 -
Rejected- EPSDT Form Not Submitted with Claim Form (applicable
to dates of service prior to 1/1/02)
This code is discontinued.
D32 -
Denied - Prior PaymentsEqual DME Purchase Price
A DME item can be rented from aprovider for a Gateway member.
If it isrented, payments will only be made until the purchase
price is reached.
D33 -
Rejected - Charges Were Not Submitted
The provider did not submit a charge for a billed procedure
code; therefore, Gateway will not render any payment since
the provider did not indicate what charges he or she is
billing for this service. Primary Care Physicians do
not have to submit charges for capitated services.
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 onthe
EOB or the claims system cannot determine a correct payment.
Therefore, further detail is requested fromthe 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 onthe bill.
D35 -
Rejected Submitted BillDoes Not Match Authorization
When the Utilization Management Department issues an Authorization
for a service orprocedure, the date of service(s), provider
number and procedure code(s) shouldmatch the information
submitted on the bill. If the information on
the bill does not match the authorization, theclaim may
be rejected as Gateway Health Plan® is unable to determine
if the authorized service is the same as the service on the
bill.
D36 -
Rejected -Discrepancy inthe Level of Care Provided with
the Authorization
When the Utilization Management Department issues an Authorization
for a service orprocedure, the level of care provided must
be defined. For example, an inpatient stay will have
abed 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 Contractedand/or Authorized Procedure
Code(s) for Ambulance/Transport Services
All ambulance/transport providersare required to bill Gateway
with procedure codes that are contracted and/orauthorized
for reimbursement.
D38 -
Baby NotEnrolled in Plan; Refile with the Baby’s
Gateway ID Number
A baby is not added to the GatewayHealth Plan coverage until
the mother’s MA caseworker processes the MA-112 formfrom
the hospital. Once this iscomplete, the baby is assigned
a recipient number and can be enrolled inGateway Health
Plan (retroactive to the birth date). This process
usually takes 6-8 weeks.
D39 -
Rejected -Refile with Gateway Member
ID Number
Member information is incorrect/incomplete
and we cannot identify the Gateway Health Plan® member.
Please resubmit claim with correct information.
D41 -
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 isnot
indicated or listed in another area of the form, appropriate
payment can not be determined. Please resubmit.
D41 -
InformalReview Denial
This code is discontinued.
D42 -
Non-ParInformal Review Denial
This code is discontinued.
D43
- Resubmit Claim toDental Carrier
By contractual agreement, dentalservices are covered for
Gateway members by another carrier. Claims
and all relateddocumentation must be submitted directly
to this carrier. Refer to the Member
Benefits section of the Policy and
Procedure manual for more details.
D44 -
Submit Claim to BHProvider
Behavioral Health services formembers are limited to Emergency
Room services that donot result in
an in-patient admission. Please resubmit claim to correct
payer.
D45 -
Medical Services NotApproved
The services provided for medical care (other than Emergency
Room ) were not approved. Medical documentation
has been reviewed by autilization review nurse and the Gateway
Health Plan (GHP) PhysicianAdvisor. The Physician
Advisor makesthe final determination of payment or denial.
D46 -
Medical Records AreInsufficient
This code indicates thatdocumentation was received, but
the medical records received are not sufficientto render
a decision (illegible notes, insufficient documentation
of symptoms,etc.).
D47 -
Rejected- ProviderNumber And Tax ID Number Do Not Match
This code is used when the claimcannot be processed since
the provider number and the tax identification numberdo
not match information contained in Gateway’s records.
Please submit documentation to allow recordsto be updated.
D48 -
Denied- Diagnosis not consistent with Medical Review
This code is used when a review ofmedical records has been
conducted, and the findings in the records are used toreverse
a previously paid claim. Finaldetermination of claim
payment is based on the results of the medical records.
D50
- Denied forMultiple Reasons
This code is discontinued.
D51 -
Denied- Services Billed Under Newborn Number
Claim incorrectly billed undernewborn ID number.
D52 -
Denied- Services Not Paid Until Confinement Ends
Payment of charges applicable to DRGreimbursement is not
issued until discharge diagnosis submitted.
D53 -
LabNot Authorized or Performed by Non-Capitated Provider
This code is used when lab servicesare rendered by a provider
other than the member’s capitated lab provider.
Additionally, if a member does not have acapitated lab provider,
the code is used to designate that a referral/auth hasnot
been obtained.
D54 -
Deny- No Referral after 1st/2nd Review
This code is used for specialproject purposes to identify
if referrals are submitted after the claim isreceived for
payment.
D55 - Claims
Combined for Editing
Claims finalized by the claims processor
but not yetupdated in the claims system through the A/P
process are denied if charges on anew claim result in a
coding edit applicable to both claims. The original claimis
denied and all services are processed on a single claim.
D56 -
Prof Fees Must Be Billed With AModifier
Charges that require modifiers to allow appropriate reimbursement
willbe rejected to alert providers of correct billing procedures.
D57 -
Rejected DRG Code Required
Inpatient claims that require a DRG code for payment determination
willbe rejected if the DRG code is not included on the claim.
D58 -
Deny Administrative
This code should be used only for claims resulting from
deniedauthorizations by NIA for CT Scans/MRI services.
D59 -
Deny Retrodisenrollment Submitto MA
Claims that are adjusted due to delayed
notification ofa disenrollment received by Gateway Health
Plan will be reprocessed and deniedwith 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 besubmitted with one of the following codes:
J3490, J7599, J7799, J8499, J8999,J9999 or 90799 along with
NDC code, drug name, dosage and quantity to beprocessed.
Claims submitted with an unclassified
J code and NDC that appear to include anincorrect quantity
will be denied for provider review of NDC and/or quantity.
D61 -
Procedures ForBilling W/Group, Referring,
Performing Provider Were NotFollowed (Code will be
used withManagement Approval Only)
This code is discontinued.
D62 -
Rejected - Sex Discrepancy Relatedto the Procedure Code
Billed; Refile
(New code eff. 8/12/03 see D3 forAge Discrepancy note)
The procedure code submitted is not appropriate based on
the sex of themember.
D63 -
Rejected - Expenses Incurred Prior To Coverage
(New code eff. 8/12/03 see D8 fordenial 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 a referral or 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 Member Sectionof the Policy
and Procedure manual for more details.
D64 -
Rejected Services Mustbe Billed on a CMS or UB
EPSDT services billed on an MA-517form for dates of services
on or after 3/1/04 will be denied with this code toconvey
that only CMS or UB forms are acceptable. Other services
billed on non-standard forms will also be deniedwith this
code.
D65 Denied Paper UBForms
Cannot be Processed Unless a Valid Type of Bill is Submitted
in Field 4;Resubmit
The Type of Bill is requiredon UB forms for claims processing
purposes. Electronic Claims will
be rejected by the clearinghouseand paper claims will be
rejected through the claims system.
D66 Denied Claim Does Not
Have ANY DiagnosisCode(s) on the Bill. One or More
ValidDiagnosis Code(s) Required; Resubmit
Claims submittedwithout any diagnosis
code cannot be processed. Every bill must have a minimum
of one diagnosis code submitted orit will be denied with
code D66. Claimssubmitted with invalid diagnosis code(s)
for the date of service will result ina claim denial under
a different adjustment code.
D67 Denied Infertility
Services are not Covered Under MA or Gateway
Claim lines submitted with adiagnosis code or for a service
for infertility are not eligible forreimbursement by Gateway
Health Plan.
D68 Denied Renal Dialysis
Services are not a partof 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®.
RemarkCodes
R1 -
CapitatedService
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’spayment was included
in Gateway Health Plan’s calculation. Payment
allowed represents GHP’s contracted liability less
the primary carrier’s payment (based on approved/contractedamount)
for the service(s).
R3 -
Combined Mother & BabyPayment
Payment for this service reflectscompensation for both mother
and baby charges during an inpatient deliverystay.
R4 -
Interim Bill Payment
This payment is recognized to be aninterim payment and may
be recalculated based on contractual agreement uponreceipt
of a final bill.
R5 -
Contracted/Negotiated Rate
Payment for this service was made ata special contracted
or negotiated rate with the provider of service.
R6 -
Reprocessed and Corrected
There are times during theprocessing of a claim when a processor
makes an error and it is discoveredduring an accuracy audit.
In thisinstance, this remarks code may be applied to the
reprocessing of the claim.
R7 -
Paid at Quantity Specifiedin the Authorization
When the Utilization ManagementDepartment issues an authorization,
the quantity of the procedure or servicemust be defined.
In the event that thequantity on the bill exceeds that in
the authorization, then the additionalquantities are not
considered for additional payment.
R8 -
ClaimResolution Finalized
This code allows any claim requiringadditional investigation
to be finalized in accordance with current dataincluded
in the claim system.
R9 -
TPLRefund to DPW
This code is used to redirectpayment to DPW when Gateway receives
a refund from a provider for a TPL expense forwhich Gateway
is obligated to pay.
R10 -
NoncleanEDI - Provider/Member # Not
Submitted
Claims processingcriteria included
incorrect/incomplete information and additional research
wasrequired for an electronically received claim.
R11 -
Fee/CodeUpdate Completed
This code is applicable to claim adjustments resulting from
coding changes and the Remarks code is restricted tousage
only by the claim review dept.
R12 -
Payment ReflectsInterest Amount
This code is used to identify claims paid with interest
on aremittance advice due to investigation of a delayed
payment.
R13 -
Paymentreflects Medicare COB
This claim reflects coordination of benefits with Medicare
as the primary carrier. Gateway determinesits cost-sharing
liability by calculating the difference between the GHPcontracted
rate and the amount Medicare pays (including adjustments
forMedicare approved amounts and contractual allowances).
R14 -
EPSDTProcessed After MA ID Number Research (Code discontinued
for dates of service of3/1/04 or after)
Claims submitted by providers on MA
517EPSDT forms (effective 10/1/01 2/29/04) that do not have
a crossreference to an MA ID number in GHP’s records
will be researched and GHP’sprovider record will be
updated. Theclaim will be processed after the
update is completed.
R15 -
AmountPaid Represents EPSDT Reimbursement
(Applicable forDates of Service of 3/1/04 or later)
Payment for claims processed forEPSDT services will reflect
the provider’s contracted rate for code S0302 whenbilled
along with the appropriate 993XX preventive medicine evaluation
andmanagement code.
R20 -
Invalid Place of Service Code May Have Been Corrected To
Allow Payment
CMS-1500 Place of Service Codesare used by Gateway to process
claims. This notification is to make you aware that
the code on the claim wasincorrect. If payment was
not affectedby the erroneous place of service code, it was
not changed. If payment was affected by the erroneousplace
of service code, it was changed to allow proper reimbursement.
Please review place service codes andutilize CMS-1500 codes
for claims submission to Gateway.
Adjusted/Appealed/Corrected Codes
A1 -
Adjustment to/Recovery ofPrevious Payment
Additional payment has been approvedfor this service OR
the service was over-paid OR is aduplicate payment and money
has been subtracted to correct the error.
A2 -
Administrative/MedicalAdjustment
Payment for this claim has been allowedoutside normal processing
guidelines. Although the service may not have had approval
from the PCP or GatewayHealth Plan, the situation is one
where medical attention was warranted ORwhere payment is
deemed appropriate by administrative personnel of GatewayHealth
Plan.
A3 -
Appeal - Denial Overturned
This service has been reconsideredas a result of an appeal
by the provider and the original decision to deny theservice/claim
has been overturned.
A4 -
Appeal - Denial Upheld
This service has been reconsideredas a result of an appeal
by the provider and the original decision to deny theservice/claim
has been upheld.
A5 -
Appeal - Payment Upheld
This service has been reconsideredas a result of an appeal
by the provider and the original decision to pay thisclaim
has been upheld. The originalpayment is considered
to be a final and complete payment.
A6 -
Claim Processing Error -Claim Corrected
This is a claim correction due to adata keying error of
information provided on a claim form that was made by aGateway
Health Plan claims processor.
A7 -
Incorrect Quantity -Claim Corrected
This is a claim correction as aresult of an error in keying
the correct quantity of a procedure or inoverlooking additional
claim documentation referencing the quantity of serviceprovided.
A8 -
Emergent Diagnosis
This claim has been processed forpayment because any of
the diagnoses submitted for the emergency room servicesallow
the claim to be paid.
A9 -
Authorized Emergency Room Visit
This claim has been processed forpayment because the provider
received approval for an emergency room visit fromeither
the member’s PCP or from Gateway’s Utilization
Management Department.
A10 -
AuthorizedLiability
The original liability on anauthorization was changed to
allow a claim to be attached to the authorizationand paid.
A10 is used only for internalpurposes at Gateway and will
not appear on a remittance advice.
A11 -
Additional FormsReceived; Claim Reprocessed
The claim is now eligible to beprocessed correctly, because
additional forms were received by the provider(i.e., an
itemized bill, an invoice, etc.).
A12 -
Appeal Denied; MedicalRecords are Insufficient
This code is discontinued.
A13 -
Appeal Denied; Does NotMeet Emergency Room
Criteria
This code is discontinued.
A14 -
Check Return/Refund;Claim Reprocessed
This adjustment code is used toindicate the reprocessing
of a claim that has been associated with a returnedor refunded
check submitted by the provider.
A15 -
Referral Found after Additional Review
This code is used for specialproject purposes to identify
if referrals are submitted after the claim isreceived for
payment.
A16- Claim Reversed
for Editing
This code is used to reverse aservice previously submitted
and processed when a charge on a new claim resultsin a coding
edit applicable to both services - the original claim is
reversedand all services are processed on the current claim.
A17 -
SeeMember ID# - Please Update Records
Claims that are received electronically
withincorrect Gateway member ID# are reviewed to attempt to
process the claim the firsttime it is received. If
the claim is processed, this note notifies the provider
that information in their recordsneeds to be updated/corrected.
A18 -
Adj Reflects CostOutlier Payment
(Please note wording changed on 8/12/03 see A20 for DayOutlier
note)
Gateway proactively reviews recent claim payment activity toidentify
if an outlier payment is due to a participating DRG hospitalfacility.
Claims that are assigned this code
reflect adjustments made as a result of cost outliercriteria.
A19 -
Adj Hosp Readmissionwithin 30 Days
Gateway complies with MA criteria in administering readmissionsfor
the same DRG within a 30-day period of a prior hospital
admission. Claims for readmissions
to the same facility for the same DRG are combined and all
dates of services are considered as the same period of hospital
confinement.
A20 -
Adj Reflects DayOutlier Payment
(New code eff. 8/12/03 see A18
forCost Outlier note)
Gateway proactively reviews recent claim payment activity to
identify if an outlier payment is due to a participating
DRG hospitalfacility. Claims
that are assigned this code reflect adjustments made as
a result of day outlier criteria.
A21 -
Adj DRG Payment Due to Hospital Transfer
Gateway complies with MA criteria for hospital transfers from
one DRGreimbursed facility to another. Hospital charges
for the facility initially admitting the patient areallowed
at a prorated DRG amount for each day of approved care.
Claim Line Changes
C17 - Procedure Code
Replaced or Rebundled
This adjustment code is a genericcode to identify any claim
line that has been replaced or rebundled to meetplan criteria.
The claim line(s) thatreplace(s) the submitted charges will
appear separately on the claim. This code has been
instituted to meet HIPAArequirements.
C18 -
DefaultClaim Line Denial
The adjustment code is a genericcode to identify any claim
line that does not warrant any payment. The claim
line(s) that replace(s) thesubmitted charges will appear
separately on the claim. This code has been instituted
to meet HIPAArequirements and will most frequently apply
to claim lines audited by GHP’scoding program.
|
Medicaid |
|
|