COMMON INSURANCE DENIALS & ACTIONS

Denial Code (Remarks): PR 1

Denial reason: Deductible amount
Denial Action: Billed to secondary insurance/patient
Denial Code (Remarks): PR 2
Denial reason: Coinsurance amount
Denial Action: Billed to secondary insurance/patient
Denial Code (Remarks): PR 3
Denial reason: Copay amount
Denial Action: Billed to secondary insurance/patient
Denial Code (Remarks): CO 4
Denial reason: The procedure code is inconsistent with the modifier used or a required
modifier is missing.
Denial Action: Use appropriate modifier with respective of procedure
Denial Code (Remarks): CO 5
Denial reason: The procedure code/bill type is inconsistent with the place of service.
Denial Action: Correct the Place of service or correct the procedure with respect of place
of service.
Denial Code (Remarks): CO 6
Denial reason: The procedure/revenue code is inconsistent with the patient's age.
Denial Action: Correct the procedure code with respect of patient's age
Denial Code (Remarks): CO 7
Denial reason: The procedure/revenue code is inconsistent with the patient's gender.
Denial Action: Correct the procedure code with respect of patient's gender (SexMale/Female)
Denial Code (Remarks): CO 9
Denial reason: The diagnosis is inconsistent with the patient's age.
Denial Action: : Correct the diagnosis code with respect of patient's age
Denial Code (Remarks): CO 10
Denial reason:The diagnosis is inconsistent with the patient's gender.
Denial Action: : Correct the diagnosis code with respect of patient's gender (SexMale/Female)
Denial Code (Remarks): CO 11
Denial reason: The diagnosis is inconsistent with the procedure.
Denial Action: : Correct the diagnosis code.
Denial Code (Remarks): CO 13
Denial reason: The date of death precedes the date of service.
Denial Action: : Correct the Date of service
Denial Code (Remarks): CO 14
Denial reason: The date of birth follows the date of service.
Denial Action: : Correct the Date of service
Denial Code (Remarks): CO 15
Denial reason: Payment adjusted because the submitted authorization number is
missing, invalid, or does not apply to the billed services or provider.

Denial Action: : Submit the claims with Authorization number or valid authorization
Denial Code (Remarks): CO 16
Denial reason: Claim/service lacks information which is needed for adjudication. At least
one Remark Code must be provided (may be comprised of either the Remittance Advice
Remark Code or NCPDP Reject Reason Code.)
Denial Action: : Check with other remark codes started as N/M and correct the claims
Denial Code (Remarks): PR 1
Denial reason: Deductible amount
Denial Action: Billed to secondary insurance/patient
Denial Code (Remarks): PR 2
Denial reason: Coinsurance amount
Denial Action: Billed to secondary insurance/patient
Denial Code (Remarks): PR 3
Denial reason: Copay amount
Denial Action: Billed to secondary insurance/patient
Denial Code (Remarks): CO 4
Denial reason: The procedure code is inconsistent with the modifier used or a required
modifier is missing.
Denial Action: Use appropriate modifier with respective of procedure
Denial Code (Remarks): CO 5
Denial reason: The procedure code/bill type is inconsistent with the place of service.
Denial Action: Correct the Place of service or correct the procedure with respect of place
of service.
Denial Code (Remarks): CO 6
Denial reason: The procedure/revenue code is inconsistent with the patient's age.
Denial Action: Correct the procedure code with respect of patient's age
Denial Code (Remarks): CO 7
Denial reason: The procedure/revenue code is inconsistent with the patient's gender.
Denial Action: Correct the procedure code with respect of patient's gender (SexMale/Female)
Denial Code (Remarks): CO 9
Denial reason: The diagnosis is inconsistent with the patient's age.
Denial Action: : Correct the diagnosis code with respect of patient's age
Denial Code (Remarks): CO 10
Denial reason:The diagnosis is inconsistent with the patient's gender.
Denial Action: : Correct the diagnosis code with respect of patient's gender (SexMale/Female)
Denial Code (Remarks): CO 11
Denial reason: The diagnosis is inconsistent with the procedure.
Denial Action: : Correct the diagnosis code.
Denial Code (Remarks): CO 13
Denial reason: The date of death precedes the date of service.
Denial Action: : Correct the Date of service
Denial Code (Remarks): CO 14
Denial reason: The date of birth follows the date of service.

Denial Action: : Correct the Date of service

Denial Code (Remarks): CO 15

Denial reason: Payment adjusted because the submitted authorization number is
missing, invalid, or does not apply to the billed services or provider.
Denial Action: : Submit the claims with Authorization number or valid authorization
Denial Code (Remarks): CO 18
Denial reason: Duplicate claim/service.
Denial Action: : Check with other remark codes started as N/M and correct the claims
Denial Code (Remarks): CO 22
Denial reason: Payment adjusted because this care may be covered by another payer per
coordination of benefits.
Denial Action: : Submit the claims to other health care insurance.
Denial Code (Remarks): CO 24
Denial reason: Payment for charges adjusted. Charges are covered under a capitation
agreement/managed care plan.
Denial Action: : Submit the claims to other health care insurance.
Denial Code (Remarks): PR 26
Denial reason: Expenses incurred prior to coverage.
Denial Action: : Bill to patient.
Denial Code (Remarks): PR 27
Denial reason: Expenses incurred after coverage terminated.
Denial Action: : Bill to patient.
Denial Code (Remarks): CO 29
Denial reason: The time limit for filing has expired.
Denial Action: : Appeal the claim with the proof of clearing house reports.
Denial Code (Remarks): PR 31
Denial reason: Claim denied as patient cannot be identified as our insured.
Denial Action: : Correct the patient name, DOB and Policy number
Denial Code (Remarks): CO 45
Denial reason: Charges exceed your contracted/ legislated fee arrangement. This change
to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or
contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon
liability).
Denial Action: : Take write off
Denial Code (Remarks): CO 50
Denial reason: These are non-covered services because this is not deemed a `medical
necessity' by the payer.
Denial Action: : Check the Diagnosis codes
Denial Code (Remarks): CO 58
Denial reason: Payment adjusted because treatment was deemed by the payer to have
been rendered in an inappropriate or invalid place of service.
Denial Action: : Correct the place of service.
Denial Code (Remarks): CO 96

Denial reason: Non-covered charge(s). At least one Remark Code must be provided (may
be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason
Code.)
Denial Action: : Correct the diagnosis codes

Denial Code (Remarks): CO 97

Denial reason:Payment adjusted because the benefit for this service is included in the
payment/allowance for another service/procedure that has already been adjudicated
Denial Action: : submit the claims with appropriate modifier
Denial Code (Remarks): OA 100
Denial reason:Payment made to patient/insured/responsible party
Denial Action: : Payment made to patient by medicare. So bill to patient for collect the
payment.
Denial Code (Remarks): OA 109
Denial reason: Claim not covered by this payer/contractor. You must send the claim to the
correct payer/contractor.
Denial Action: : Check whether it is RR medicare/DMERC and submit the claims to
appropriate carrier
Denial Code (Remarks): PR 140
Denial reason: Patient/Insured health identification number and name do not match.
Denial Action: : Correct the plicy number/patient name and submit the claims.
Denial Code (Remarks): CO 167
Denial reason: This (these) diagnosis(es) is (are) not covered.
Denial Action: : Submit the claims with correct diagnosis codes
Denial Code (Remarks): CR 181
Denial reason: Payment adjusted because this procedure code was invalid on the date of
service
Denial Action: : Submit the claims with Valid CPT
Denial Code (Remarks): CR 182
Denial reason: Payment adjusted because the procedure modifier was invalid on the date
of service
Denial Action: : Submit the claims with Valid modifier
Denial Code (Remarks): CO B10
Denial reason:t Allowed amount has been reduced because a component of the basic
procedure/test was paid. The beneficiary is not liable for more than the charge limit for
the basic procedure/test.
Denial Action: : Always payment has been reduced for multiple procedure. While
submitting the multiple procedure, submit the high amount line item in first.
Denial Code (Remarks): OA B13
Denial reason:t Previously paid. Payment for this claim/service may have been provided
in a previous payment.
Denial Action: : Claim has been already paid, Check with EOB
Denial Code (Remarks): CO B14
Denial reason:t Payment denied because only one visit or consultation per physician per
day is covered.
Denial Action: : Take write off for duplicate claim or check the DOS and submit the claims
Denial Code (Remarks): CO B16

Denial reason:t Payment adjusted because `New Patient' qualifications were not met.
Denial Action: : Submit the claims with established patient visit
Denial Code (Remarks): PR B9
Denial reason:t Services not covered because the patient is enrolled in a Hospice.
Denial Action: : Submit the claims with GV modifier