| Code | Current Narrative | Notes |
| 42 | Charges exceed our fee schedule or maximum allowable amount.
Note: Changed as of 10/06. This code will be deactivated on 6/1/2007. | Modified as of 10/06 Effective 6/1/2007 |
| 45 | 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).
Note: Changed as of 10/06 | Modified as of 10/06
Effective 6/1/2007
Note: This code replaces code 42 (above) on June 1, 2007. |
| 62 | Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Note: Changed as of 2/01 and 10/06. This code will be deactivated on 4/1/2007. | Modified as of 10/06 |
| 97 | Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
Note: Changed as of 2/99 and 10/06 | Modified as of 10/06 |
| 107 | Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
Note: Changed as of 6/03 and 10/06. | Modified as of 10/06 |
| 136 | Claim adjusted based on failure to follow prior payer's coverage rules. (Use Group Code OA).
Note: Changed as of 6/00 and 10/06. | Modified as of 10/06 |
| 196 | Claim/service denied based on prior payer's coverage determination.
Note: New as of 6/06. Changed 10/06. This code will be deactivated on 2/1/2007, beginning on that date, value 136 will be used. | Modified as of 10/06 |
| A1 | Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code). Note: Changed as of 10/06 | Modified as of 10/06 |
| B15 | Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
Note: Changed as of 2/01 and 10/06. | Modified as of 10/06 |
| D17 | Claim/Service has invalid non-covered days.
Note: This code will be deactivated on 2/1/2007 and code 16 will then be used with appropriate claim payment remark code [M32, M33]. | Modified as of 10/06 |
| D18 | Claim/Service has missing diagnosis information.
Note: This code will be deactivated on 2/1/2007 and then code 16 will be used with appropriate claim payment remark code [MA63, MA65]. | Modified as of 10/06 |
| D19 | Claim/Service lacks Physician/Operative or other supporting documentation
Note: This code will be deactivated on 2/1/2007 and code 16 will be used with appropriate claim payment remark code [M29, M30, M35, M66]. | Modified as of 10/06 |
| D20 | Claim/Service missing service/product information.
Note: This code will be deactivated on 2/1/2007 and code 16 will be used with appropriate claim payment remark code [M20, M67, M19, MA67]. | Modified as of 10/06 |
| D21 | This (these) diagnosis(es) is (are) missing or are invalid Note: New as of 6/05. This code will be deactivated on 2/1/2007. | Modified as of 10/06 |
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