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# - Remarks Code to Identify a Gateway Processing/Payment Rule
- A# - Claim Adjusted/Appealed/Corrected Code
- C# - Coding to identify claim line changes
Rejection/Denial Codes
D1 - Rejected - Medical Records Required
The patient’s medical records are requested 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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D3 - Rejected - Age Discrepancy Related to the 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 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 W/In 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 w/Dates of Service Required; Refile
Multiple dates of services must be itemized on the 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 the 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’s 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 Claim Filing Time
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
Based on existing other 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 - Provider’s Bill and the 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 - (THIS CODE IS NOT APPLICABLE TO MEDICARE)
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 Pharmacy Carrier Responsible for this Service
By contractual agreement, Part D 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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D22 - Rejected - No/Invalid/Expired Precert
Certain services require precertification (authorization) from Gateway Health Plan’s Utilization Management Department. A provider must call the Utilization Management 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 Utilization Management Department. Retrospective precertification will not be given. If the services rendered were in support of another provider, please confer with that provider regarding precertification obtained. See the precertification section of the Policy and Procedure manual for more details.
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’s 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.
D24 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D25 - Denied - Duplicate Claim - Paid/Denied Correctly 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 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 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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D29 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D30 - Denied - Additional Information Needed to Support Payment
This code is used to designate that a required form or appropriate codes were not submitted (e.g. Prenatal Risk Assessment Form.)
D31 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
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 Were Not Submitted on Bill
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.
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 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.
D35 - Rejected - Submitted Bill Does Not Match Authorization
When the Utilization Management Department issues an Authorization for a service or procedure, the date of service(s), provider number and procedure code(s) should match the information submitted on the bill. If the information on the bill does not match the authorization, the claim 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 in the Level of Care Provided with the 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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
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.
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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D42 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D43 - Resubmit Claim to Dental Carrier (NOT APPLICABLE TO 2007 SERVICES)
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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D45 - Medical Services Not Approved
The services provided for medical care (other than Emergency Room) were not approved. Medical documentation has been reviewed by a utilization review nurse and the Gateway Health Plan® Physician Advisor. The Physician Advisor makes the final determination of payment or denial.
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 Number And Tax ID Number Do Not Match
This code is used when the claim cannot be processed since the provider 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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
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 reimbursement is not issued until discharge diagnosis submitted.
D53 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D54 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
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 - Prof 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 - Deny - Retrodisenrollment - Submit to Medial 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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D61 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D62 - Rejected - Sex Discrepancy Related to the Procedure Code Billed; Refile
The procedure code submitted is not appropriate based on the sex of the member.
D63 - Rejected - Expenses Incurred Prior To Coverage
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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
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 code cannot be processed. Every bill must have a minimum of one diagnosis code submitted or it will be denied. Claims submitted with invalid diagnosis code(s) for the date of service will result in a claim denial under a different adjustment code.
D67 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D68 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D69 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D70 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D71 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D72 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D73 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D74 - XRAY’S Performed by a Chiropractor are not Reimbursable
The medical plan does not allow xray’s performed by a Chiropractor.
D75 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D76 - Denied - Autopsy Related Services are not Covered
The medical plan does not cover autopsy related services.
D77 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D78 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D79 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
D80 - Our Records Show the Date of Service was after the Date of Death
D81 - Denied - Prov Opted Out of Medicare and Patient is Resp for Payment Up to Limiting Charge Amount
D82 - Denied - Services by Non Plan Providers in Non-Emergency Situations Are Not Payable by Gateway Health Plan Medicare AssuredSM
D83 - Denied - Out of Area Services are Not Covered if Non-Emergent/Urgent or Not Authorized by Gateway Health Plan Medicare AssuredSM
D84 - Denied - 190 Day Lifetime Maximum in a Medicare Certified Psychiatric Hospital Has Been Exceeded
D85 - Denied - 100 Day Maximum Per Benefit Period for In-Patient Skilled Nursing Facility Services Has Been Exceeded
D86 - Denied - Services Not Covered because the Patient is Enrolled in a Hospice
D87 - Denied - These are Non-Covered Services because this is a Routine Exam or Screening Procedure in conjunction with a Routine Exam
D88 - Denied - Renal Facilities Not Certified/Eligible to be Paid for this Procedure/Service on this Date of Service
D89 - Medicare Fiscal Intermediary is Carrier for Medicare Covered Family Planning Services
Instructions for this code are to advise providers to bill Gateway and upon receipt of denial,
they are to send claim to Fiscal Intermediary. Address for PA Medicare Assured® member claims is as follows: Highmark Medicare Services, Attn: Moral & Religious Exceptions, PO Box 890418, Camp Hill, PA 17089-0418, Phone: 1-866-488-0548. Address for Ohio Medicare AssuredSM member claims is as follows: Palmetto GBA, Attn: Moral & Religious Exceptions, PO Box 182932, Columbus, OH 43218-2932, Phone: 1-877-567-9232. Appeals Address for PA Medicare AssuredSM member claims is as follows: Highmark Medicare Services, PA Part A Appeals, PO Box 890385, Camp Hill, PA 17089-0385.
D90 - Missing/Incomplete/Invalid Claim Information. Resubmit Claim After Corrections.
This code will be used when required information to process the claim is not included. An example includes: dialysis claims without value codes A8 or A9.
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 - Denied - Not Covered by National or Local Coverage Determination
Gateway will not cover or reimburse services determined by CMS National or Local Coverage Determinations as not covered by Medicare.
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 Medicare.
D94 - Home Adaptation Items Provided by a NonParticipating Provider are not a Covered Benefit of Medicare Assured®
Gateway allows payment for home adaptation items that meet plan criteria for coverage.
D95 - Denied – This Procedure Code is not Compensable under Gateway's Medicare Assured® Plan
Gateway will auto deny codes that represent services not allowable under original Medicare or Medicare Assured®.
Remark Codes
R1 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
R2 - Payment Reflects Non-Medicare COB
The primary insurance carrier’s payment was included in Gateway Health Plan’s calculation. Payment allowed represents Gateway’s contracted liability less the primary carrier’s payment (based on approved/contracted amount) for the service(s).
R3 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
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 and Corrected
There are times during the processing of a claim when a processor makes an error and it is discovered during an accuracy audit. In this instance, this remarks code may be applied to the reprocessing of the claim.
R7 - Paid at Quantity Specified in the Authorization
When the Utilization Management Department issues an authorization, the quantity of the procedure or service must be defined. In the event that the quantity on the bill exceeds that in the authorization, then the additional quantities are not considered for additional payment.
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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
R10 - Nonclean EDI - Provider/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 Reflects Interest Amount
This code is used to identify claims paid with interest on a remittance advice due to investigation of a delayed payment.
R13 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
R14 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
R15 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
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 submission to Gateway.
R21 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
Adjusted/Appealed/Corrected Codes
A1 - Adjustment to Recovery of 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 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 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 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 - Claim 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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
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 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
A13 - (NOT APPLICABLE TO MEDICARE - DO NOT USE)
A14 - Check Return/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 -(NOT APPLICABLE TO MEDICARE - DO NOT USE)
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
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 adjustments made as a result of cost outlier criteria.
A19 - Adjustment - Hospital Readmission
Gateway complies with criteria for readmissions due to a prior hospital admission. Claims for readmissions to the same facility are combined and all dates of services are considered as the same period of hospital confinement.
A20 - Adjustment – Reflects Day Outlier Payment
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.
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.
Claim Line Changes
CC - Code Added Per ClaimCheck Editing
If ClaimCheck adds a new line (i.e. due to rebundling/replacement) with a code that was not submitted by the provider, this edit will be displayed.
CC1 - Assistant Surgeon or Physician Assistant Not Required
Standard clinical guidelines as reviewed and implemented by Gateway Health Plan® reflect that this service does not warrant an assistant surgeon.
CC2 - Replaced New Visit With Established
CPT guidelines allow one new patient visit per provider once per a three year period. If charges for a new patient visit are received more frequently, codes are replaced with comparable established patient visit codes.
CC3 - Code Not Used
CC4 - Denied-Services Within Surgery PostOp Date Range
Evaluation and management services rendered within the post operative timeframes as defined by CMS1500 for a surgery code are denied. The charges will be denied even if there is a referral in the claims system.
CC5 - Denied-Services Within Surgery PreOp Date Range
Evaluation and management services rendered within the pre operative timeframes as defined by HCFA for a surgery code are denied. The charges will be denied even if there is a referral in the claims system.
CC6 - Duplicate Procedure Performed
Some procedures qualify for payment only if billed once/date of service or once in a patient's lifetime. Services which exceed any of these limits are not payable.
CC7 - Requested Amount Modified
Requested amounts billed on the current claim are modified when a charge is found in history that is billed with a separate code and separate charge. If a new code is applied that more accurately reflects the actual service rather than the two separate codes, the requested amount for the new code is equal to the amounts previously requested on the original codes. The payable amount represents the amount allowed by the claims system for the new code.
CC8 - Services Itemized for Claim Editing
Procedures billed with the units field indicating more than a quantity of 1 will have their units expanded into multiple lines to allow claims editing to be applied.
CC9 - Auto-Adjust
The paid amount on the current claim has been reduced due to a previously paid service in history. If the billed amount on the current claim indicates that the service previously billed and paid needs to be adjusted, the adjustment for both charges will be made on the current claim to reflect the appropriate total payment.
C10 - All Lines Denied – Different Adjustment Codes
If there are multiple adjustment codes indicated on a claim (any combination of ClaimCheck and/or claim denials), this code will be used to indicate that the individual reasons could not be provided. The claims system allows only one adjustment code per denied claim to be used. Use of this code will designate that the claim was reviewed by ClaimCheck.
C11 - Replaced for Intensity of Service Vs Diagnosis
Evaluation and management claims submitted with an individual diagnosis code and billed with a code that reflects a higher than expected intensity of service will be edited. The E&M code will be replaced with one that more accurately reflects the appropriate level of service.
C12 - Multiple Procedure Plan Limit
Payment for this service has been adjusted in accordance with multiple procedure percentage allowances.
C13 - Medical Visit No Payment
The evaluation and management procedure code has been examined and it was determined that the visit was not indicated for separate reimbursement.
C14 - Incidental Procedure No Payment
The procedure reviewed was performed with the primary procedure. It usually requires little additional effort and is considered incidental to the primary procedure. No additional payment will be rendered for this procedure.
C15 - Mutually Exclusive Procedures
A procedure code was billed with another procedure, which by clinical practice standards and/or CPT4 guidelines should not be performed on the same patient on the same date of service.
C16 - Rebundling of Codes
The billed procedure codes have been examined and it was determined that certain codes were unbundled when billed. Those codes have been rebundled into the global CPT4 code that more accurately reflects the comprehensive nature of the service that was provided.
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.
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