HIPAA Status Code To DHS EOB Crosswalk 854 Id 019833~2
User Manual: EOB 854
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Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 001 178, 193-194, 199EOB CODE NOT USED 200, 216, 218-219, 226, 228, 235, 243, 282, 371, 441-442, 444, 448-449, 452, 457-487, 490-491, 493496, 506-509, 521530, 534, 537, 552, 557-559, 562, 567571, 573-575, 579, 653, 697, 703-704, 706, 710, 716, 721768, 800-811, 814819, 821-822, 832, 841, 849, 851-852, 860-865, 869, 882886, 893-894, 897 001 192 INVD CONSV BEG END DT 001 900 CLAIM LINE IN PROCESS 001 901 001 905 001 906 001 907 STERILIZATION FORM DOS NOT MEET FEDERAL REQUIREMENTS THIS CLAIM WAS DENIED BY MEDICAL ASSISTANCE CONSULTANTS MA DOES NOT COVER REDUCTIONS BY MEDICARE SERVICE IS NOT COVERED BY MA 001 908 LINE ITEM CHARGES MUST BE BILLED TO MA AT THE RATE THE RECIPIENT WOULD OTHERWISE BE LIABLE TO PAY 001 915 REBILL WITH SPECIFIC PROCEDURE CODE 001 917 PROVIDER MUST ACCEPT INSURANCE PLAN PAYMENT AS PAYMENT IN FULL WHEN A THIRD PARTY PAYER CONTRACT SPECIFIES FULL REIMBURSEMENT. 001 918 001 919 001 920 TPL COV IS PRIMARY-MUST FOLLOW PLAN RULES OVER YEAR OLD. DOES NOT MEET PAYMENT CRITERIA DOLLAR AMOUNT ON CLAIM DOES NOT MATCH DOLLAR AMOUNT ON MEDICARE EOB 001 922 001 923 001 924 001 925 001 927 SERVICE ON CLAIM DOES NOT MATCH SERVICE ON MEDICARE EOMB. MEDICARE CLAIM PAYMENT DATE IS MISSING FROM EOB; RESUBMIT FULL EOMB REQ FORMS FOR ABORTION ARE MISSING OR INCOMPLETE MEDICARE EOB INFO DOES NOT MATCH CLAIM INFO TPL DENIAL MISSING EXPLANATION OF DENIAL REASON CODE 1 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 001 928 001 931 THE DOCUMENTATION PROVIDED DOES NOT MEET CRITERIA FOR PAYMENT ADDITIONAL PAYMENT IS NOT WARRANTED 001 934 THIS SERVICE IS BUNDLED WITH ANOTHER SERVICE; NO ADDITIONAL PAYMENT IS MADE 001 936 CONTACT THE FINANCIAL WORKER AT THE LOCAL HUMAN SERVICES AGENCY FOR ASSISTANCE IN OBTAINING PATIENT COOPERATION FOR INSURANCE BILLING 001 955 001 974 PROVIDER IS NOT ENROLLED TO PERFORM THIS SERVICE RESUBMIT CLAIM WITH MANUFACTURER'S STATEMENT CCTAD 002 MORE DETAILED INFORMATION IN LETTER. 648 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 269 CASE MIX CHANGE DURING SVC PER 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 303 ORGAN TRANSPLANT SVS NOT COV'D 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 318 NSF NOT COVERED BY PPHP PLAN 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 398 DD SCREENING DOC MISS/INVALID 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 404 THERAPY INCLUDED IN RATE 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM 615 HOSP RATE INCLUDES CRNA SERV 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM 649 NON COVD SERVICE FOR MNCARE 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 672 STERIL RECIP UNDER AGE 21 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 702 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 707 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 717 B & C LEAVE DAYS NOT ALLOWED/ OCCUPANCY RATE. BOARD AND CARE CANNOT BE BILLED IN MONTH OF SERV EOB CODE NOT USED 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 718 EOB CODE NOT USED 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 719 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 720 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 845 LTC HOSPITAL LKEAVE EXCEEDS 18 CONSECUTIVE DAYS LTC PAID PLUS CLAIMED COINSURANCE DAYS EXCEED ANNUAL MAXIMUM CLM ALREADY CRED OR REPLCD 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 875 DUPLICATE STERIL CLM 009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 887 ACCOUNT CODE MISMATCH 009 No payment will be made for this claim. 903 009 No payment will be made for this claim. 912 PROVIDER REQUESTED CLAIM OR LINE BE DENIED ALLOWED CHARGE IS LESS THAN PRIOR PAYMENT 2 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 012 ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED. 631 ASC PACKAGE SERVICE DENIAL 012 ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED. 633 PAY C&TC AS A PACKAGE 012 ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED. 636 RELATED BUNDLED SERVICE DENIED 012 ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED. 876 MULTICHANNEL LAB BLNG POS 012 ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED. 888 MULTICHANNEL LAB BLNG CNFL 021 MISSING OR INVALID INFORMATION 115 LTC DISCH DATE/LA SPAN CNFL 021 MISSING OR INVALID INFORMATION 121 CAP MULT RATE CELLS 021 MISSING OR INVALID INFORMATION 123 DATE BILLED IS MIS OR INV 021 MISSING OR INVALID INFORMATION 131 PAY-TO PROV SIG MISSING 021 MISSING OR INVALID INFORMATION 142 FAMILY PLANNING IND INV 021 MISSING OR INVALID INFORMATION 144 ANES UNITS GT 960 021 MISSING OR INVALID INFORMATION 145 DAW/UNIT DOSE CODE INVALID 021 MISSING OR INVALID INFORMATION 151 C&TC HEALTH HX NO NORM OR REF 021 MISSING OR INVALID INFORMATION 156 DATE BILLED GT BATCH DATE 021 MISSING OR INVALID INFORMATION 157 LI COUNT IS ZERO 021 MISSING OR INVALID INFORMATION 158 MCARE PART A BEN EXHAUSTED 021 MISSING OR INVALID INFORMATION 159 EOB LI INVALID 021 MISSING OR INVALID INFORMATION 162 REFILL NBR IS MIS OR INV 021 MISSING OR INVALID INFORMATION 165 MCARE CARRIER ID MIS OR INV 021 MISSING OR INVALID INFORMATION 166 DENIAL REASON INVALID 021 MISSING OR INVALID INFORMATION 168 MCARE CLM GTE FILING LIMIT 021 MISSING OR INVALID INFORMATION 169 021 MISSING OR INVALID INFORMATION 170 MEDICARE CARRIER WITHOUT PRIOR PAY OR COINSURANCE PAYER CODE J REQD 021 MISSING OR INVALID INFORMATION 174 DISP PHARM INITS MISSING 021 MISSING OR INVALID INFORMATION 175 OVERRIDE LOCATION CODE INV 021 MISSING OR INVALID INFORMATION 176 REPLCMT MANUALLY PRICED CLM 021 MISSING OR INVALID INFORMATION 177 REPLCMT/CRED OF DENIED CLM 021 MISSING OR INVALID INFORMATION 184 HOSPICE UNITS OF SERV INVALID 021 MISSING OR INVALID INFORMATION 187 EOB HEADER INVALID 021 MISSING OR INVALID INFORMATION 201 REPLCMT/CRED TCN MIS OR INV 021 MISSING OR INVALID INFORMATION 202 ONE PAYER CODE OF C OR J REQD 021 MISSING OR INVALID INFORMATION 204 REF/OTHER PROV CHK DIGIT INV 021 MISSING OR INVALID INFORMATION 214 C&TC SCREENING NOT COMPLETE 021 MISSING OR INVALID INFORMATION 241 CD SVC NOT BILLED THRU CDCTF 021 MISSING OR INVALID INFORMATION 255 MCARE ICN MIS OR INV 021 MISSING OR INVALID INFORMATION 256 MCARE LI/CLAIM LI CNFL 021 MISSING OR INVALID INFORMATION 284 ENCOUNTER CLM W/O PPHP ENROLL 021 MISSING OR INVALID INFORMATION 286 MCARE PAID DATE MIS OR INV 021 MISSING OR INVALID INFORMATION 289 BLNG AGENT INVALID 021 MISSING OR INVALID INFORMATION 296 SUBMITTER ID INVALID 3 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 021 MISSING OR INVALID INFORMATION 305 C.O.S. CD/ACCTG CODE INCORRECT 021 MISSING OR INVALID INFORMATION 306 PPHP RATE CELL INVALID 021 MISSING OR INVALID INFORMATION 307 PPHP CONTRACT NOT FND 021 MISSING OR INVALID INFORMATION 309 RECIP ENROL IN PPHP - PARTIAL 021 MISSING OR INVALID INFORMATION 311 CD NOT VAL FOR AGE/PROV SP/FAC 021 MISSING OR INVALID INFORMATION 312 CD IN RTC NOT VAL/MJR PROG/AGE 021 MISSING OR INVALID INFORMATION 313 CAT OF SERV CANNOT BE DETERMIN 021 MISSING OR INVALID INFORMATION 316 BSRT PARM CNFL 021 MISSING OR INVALID INFORMATION 319 BASE RATE ADD-ON/PARM CNFL 021 DRUG INFORMATION. 330 DRUG NOT REBATABLE 021 MISSING OR INVALID INFORMATION 331 NEWBORN CODE NOT PRESENT 021 MISSING OR INVALID INFORMATION 345 C&TC IND MISSING OR INVALID 021 MISSING OR INVALID INFORMATION 350 UPC NOT ON FILE 021 MISSING OR INVALID INFORMATION 380 SCREENING MISSING 021 MISSING OR INVALID INFORMATION 381 RATE REC NOT FOUND 021 MISSING OR INVALID INFORMATION 383 PRENATAL SCREEN MISSING OR OLD 021 MISSING OR INVALID INFORMATION 385 PRENATAL SCREEN NOT PRESENT 021 MISSING OR INVALID INFORMATION 386 SCREENING TOO OLD 021 MISSING OR INVALID INFORMATION 402 DTH SERV REQUIRES TWO SIG 021 MISSING OR INVALID INFORMATION 410 MSG MISSING OR INVALID 021 MISSING OR INVALID INFORMATION 532 PROV DPA SEGMENT NOT FOUND 021 MISSING OR INVALID INFORMATION 572 MOTHER/NEWBORN SHOULD BE COMB 021 MISSING OR INVALID INFORMATION. 627 MSA CODE MISSING 021 MISSING OR INVALID INFORMATION. 630 BENLIM BKOUT NT FND 021 MISSING OR INVALID INFORMATION. 635 MULTIPLE SCRN ON SAME CLAIM 021 MISSING OR INVALID INFORMATION 654 UPC REQ TO PRICE CLAIM 021 MISSING OR INVALID INFORMATION 657 UPC NOT COVERED FOR SERV DATE 021 MISSING OR INVALID INFORMATION 669 ASC X12 REASON CODE NOT FOUND 021 MISSING OR INVALID INFORMATION 670 STERIL FORM REQD 021 MISSING OR INVALID INFORMATION 794 TELE CONTACT/FACE TO FACE CONF 021 MISSING OR INVALID INFORMATION 798 ACTION CODE MISSING OR INVALID 021 MISSING OR INVALID INFORMATION 824 INJURY CODE INVALID 021 MISSING OR INVALID INFORMATION 828 COS INVALID 021 MISSING OR INVALID INFORMATION 829 OBLIGATION ID NOT ON FILE 021 MISSING OR INVALID INFORMATION 833 MCARE REPLCMT/CRED OVERLAP 021 MISSING OR INVALID INFORMATION 836 REPL'D CLAIM HAS TPL ATTACH 021 MISSING OR INVALID INFORMATION 837 REPLCMT REASON CODE CNFL 021 MISSING OR INVALID INFORMATION 840 REPLCMT OR CRED IS IN PROCESS 021 MISSING OR INVALID INFORMATION 843 PAY-TO PROV MATCH NOT FOUND 021 MISSING OR INVALID INFORMATION 847 RELATED TCN NOT ON FILE 021 MISSING OR INVALID INFORMATION. 848 COUNTY OF FIN RESP INV 021 MISSING OR INVALID INFORMATION 850 CLM NOT FOUND ON HX 021 MISSING OR INVALID INFORMATION 853 GA CANNOT BE CRED/REPLCD 021 MISSING OR INVALID INFORMATION 854 RECIP ID/FUNDING CODE MIS 021 MISSING OR INVALID INFORMATION 855 REASON CODE NOT ALLOW 021 MISSING OR INVALID INFORMATION 856 CREDIT CANNOT BE CRED/REPLCD 021 MISSING OR INVALID INFORMATION 857 REASON CODE INVALID 021 MISSING OR INVALID INFORMATION 858 EXC OVERRIDE NOT ALLOW 021 MISSING OR INVALID INFORMATION 859 DENY EOB IS MISSING 4 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 021 MISSING OR INVALID INFORMATION 871 DTH TRANS W/O DTH SERV 021 MISSING OR INVALID INFORMATION 890 ONLY 45 HOSP DAYS ALLOWED 021 Missing or invalid information. 978 REJECTED DUE TO PROVIDER BILLING ERROR; PLEASE CALL THE PROVIDER HELP DESK FOR FURTHER INSTRUCTION. 033 SUBSCRIBER AND SUBSCRIBER ID NOT FOUND 129 RECIP ID IS MIS OR INV 033 SUBSCRIBER AND SUBSCRIBER ID NOT FOUND 251 RECIP NOT ON FILE 040 WAITING FOR FINAL APPROVAL. 179 DEBIT GROSS ADJ IS NEG 040 WAITING FOR FINAL APPROVAL. 180 CREDIT GROSS ADJ IS POS 040 WAITING FOR FINAL APPROVAL. 351 ALLOW TO SUB PERCENT DIFF EXCD 040 WAITING FOR FINAL APPROVAL. 352 SUB TO ALLOW PERCENT DIFF EXCD 040 WAITING FOR FINAL APPROVAL. 403 TRANS INCLUDED IN RATE 040 WAITING FOR FINAL APPROVAL 621 ASC SERVICE IS CPI PRICED 040 CLAIM IS OUT OF BALANCE 624 MCARE COINS PLUS DED > ALLOW 040 WAITING FOR FINAL APPROVAL. 643 ALLOW CHRG LT SURS COL AMT 040 WAITING FOR FINAL APPROVAL. 835 INTEREST DUE 040 WAITING FOR FINAL APPROVAL. 839 REPLCMT TCN IS MIS OR INV 040 WAITING FOR FINAL APPROVAL. 844 ADJ FROM HX (HISTORY) 040 WAITING FOR FINAL APPROVAL. 872 C&TC/HCFA DUPL SERV - PROV EQ 040 Waiting for final approval. 910 ATTACHMENTS WERE NOT REQUIRED FOR THE PROCESSING OF THIS CLAIM; PLEASE REFER TO THE MHCP PROVIDER MANUAL. 040 Waiting for final approval. 929 TPL ATTACH NOT REQ IF PAYMENT EXCEEDS 25% (50% FOR HOSP CHGS) YOU ARE NOT REQUIRED TO ATTACH EOB 040 Waiting for final approval. 930 TPL TERM DATE FOR THIS POLICY ENTERED INT SYSTEM; FUTURE CLAIMS FOR THIS PERSON DO NOT REQUIRED DENIAL DOCUMENTAITON. 040 Waiting for final approval. 932 INSURANCE INFO FOR THIS POLICY HS BEEN UPDATED BASED ON DOCUMETNS PREVIOUS SUBMITTED; FUTURE CLAIMS FOR THIS SERVICE/PERSON DO NOT REQUIRE DOCUMENTATION 041 SPECIAL HANDLING REQUIRED AT PAYER SITE. 113 APC OUTPATIENT DENIAL UNTIL 044 CHARGES PENDING PROVIDER AUDIT. 408 PAY-TO PROV IS UNDER REVW - SU 044 CHARGES PENDING PROVIDER AUDIT. 411 PAY-TO PROV IS UNDER REVW 044 CHARGES PENDING PROVIDER AUDIT. 414 TRTG PROV IS UNDER REVW - SURS 045 AWAITING BENEFIT DETERMINATION. 207 CATEGORY OF SERVICE SUSPENDED 045 AWAITING BENEFIT DETERMINATION. 236 MA ELIGIBILITY POSSIBLE 045 AWAITING BENEFIT DETERMINATION. 259 MULTI ELIG SPANS FOR SERV PERI 045 AWAITING BENEFIT DETERMINATION. 260 SWING BED NEEDS QMB CVRG 045 AWAITING BENEFIT DETERMINATION. 294 RECIP MAJ PROG/INPAT CLM 045 AWAITING BENEFIT DETERMINATION. 377 PROF/TECH PERCENT EQUAL ZERO 045 AWAITING BENEFIT DETERMINATION. 397 MEDICARE NUMBER 045 AWAITING BENEFIT DETERMINATION 595 CASE MIX IS MISSING 045 AWAITING BENEFIT DETERMINATION. 659 UPC NOT ALLOW FOR SERV DATE 045 AWAITING BENEFIT DETERMINATION. 699 TPL PHARM COPAY LT ALLOW CHRG 5 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 045 AWAITING BENEFIT DETERMINATION. 700 SPLIT LINE ITEM 045 AWAITING BENEFIT DETERMINATION. 834 CLIENT FEE ON CTF CLAIM 045 AWAITING BENEFIT DETERMINATION. 842 RECIP ID MATCH NOT FOUND 046 INTERNAL REVIEW/AUDIT 104 MULTI SURG REQUIRES DHS REVW 046 INTERNAL REVIEW/AUDIT 128 CLM OVER 12-MO FILING LIMIT 046 INTERNAL REVIEW/AUDIT 164 CLAIM TYPE SUSPENDED 046 INTERNAL REVIEW/AUDIT 227 046 INTERNAL REVIEW/AUDIT 325 FOLLOW UP CALC ERROR (DATE CONVERSION) TRAUMA/ACCIDENT CLM 412 TRTG PROV NOT ON FILE 046 INTERNAL REVIEW/AUDIT 413 TRTG PROV IS UNDER REVW 046 INTERNAL REVIEW/AUDIT 417 TRTG PROV UNDER REVW - CLIA 046 INTERNAL REVIEW/AUDIT 419 PAY-TO PROV UNDER REVW - CLIA 046 INTERNAL REVIEW/AUDIT 438 PROC REQUIRES MANUAL PRICING 046 INTERNAL REVIEW/AUDIT 445 INVALID LINE CNT 046 INTERNAL REVIEW/AUDIT 446 SUBMISSION CLARIF 046 INTERNAL REVIEW/AUDIT 543 AMBULANCE HOSP TO HOSP CNFL 046 INTERNAL REVIEW/AUDIT 547 NUM PROC REQ MANUAL PRICING 046 INTERNAL REVIEW/AUDIT 548 ALPHA PROC REQ MANUAL PRICING 046 INTERNAL REVIEW/AUDIT 601 APC PRICING ERROR 046 INTERNAL REVIEW/AUDIT 628 REIMB EXCEEDS DHS LIMIT 046 INTERNAL REVIEW/AUDIT 644 PA SYSTEM ERROR 046 INTERNAL REVIEW/AUDIT 645 BEN/CAP SYSTEM ERROR 046 INTERNAL REVIEW/AUDIT 652 HISTORY RECORD NOT FOUND 046 INTERNAL REVIEW/AUDIT 658 UPC REQUIRES MANUAL REVW 046 INTERNAL REVIEW/AUDIT 674 AB CONSENT NOT VALID/MAJ PROG 046 INTERNAL REVIEW/AUDIT 676 STERIL ABDOMINAL SURG/FDOS CNF 046 INTERNAL REVIEW/AUDIT 677 STERIL PERF ON INST RECIP 046 INTERNAL REVIEW/AUDIT 678 STERIL/CONSERVATOR STATUS CNFL 046 046 INTERNAL REVIEW/AUDIT 679 STERIL DELIVERY DATE EXPECTED 046 INTERNAL REVIEW/AUDIT 680 STERIL DESC OF CIRC MISSING 046 INTERNAL REVIEW/AUDIT 682 STERIL CONSENT BFR RECIP SIG 046 INTERNAL REVIEW/AUDIT 683 STERIL SIG DATE TOO OLD 046 INTERNAL REVIEW/AUDIT 684 STERIL PROV SIG/DOS CNFL 046 INTERNAL REVIEW/AUDIT 685 STERIL RECIP SIG MISSING 046 INTERNAL REVIEW/AUDIT 686 STERIL SIG DATE EQUAL TO ZERO 046 INTERNAL REVIEW/AUDIT 687 STERIL SIG DATE/FDOS CNFL 046 INTERNAL REVIEW/AUDIT 688 STERIL SIG/DEL DATE CNFL 046 INTERNAL REVIEW/AUDIT 689 STERIL CONSENT DATE MISSING 046 INTERNAL REVIEW/AUDIT 690 STERIL CONSENT SIG MISSING 046 INTERNAL REVIEW/AUDIT 691 STERIL PROV SIG MISSING 046 INTERNAL REVIEW/AUDIT 769 RPAC FILE CLOSED OR CORRUPTED 046 INTERNAL REVIEW/AUDIT 770 RPAC RECORD NOT FOUND 046 INTERNAL REVIEW/AUDIT 771 CNTRCT/PROD FILE CLOSED/CORRUP 046 INTERNAL REVIEW/AUDIT 772 CNTRCT/PROD RECORD NOT FOUND 046 INTERNAL REVIEW/AUDIT 773 MANAGED CARE CO FILE CLOSED 046 INTERNAL REVIEW/AUDIT 774 MANAGED CARE CO REC NOT FOUND 046 INTERNAL REVIEW/AUDIT 775 ESP FILE CLOSED OR CORRUPTED 046 INTERNAL REVIEW/AUDIT 776 ESP RECORD NOT FOUND 046 INTERNAL REVIEW/AUDIT 777 CTF RECIPIENT ENROLLED IN PPHP 6 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 046 INTERNAL REVIEW/AUDIT 778 RATING CRITERIA FILE CLOSED 046 INTERNAL REVIEW/AUDIT 779 RATING CRITERIA REC NOT FOUND 046 INTERNAL REVIEW/AUDIT 780 BASE RATE FILE CLOSED/CORRUPT 046 INTERNAL REVIEW/AUDIT 781 ADJUSTED RATE RECORD NOT FOUND 046 INTERNAL REVIEW/AUDIT 782 ADJ RATE FILE CLOSED/CORRUPTED 046 INTERNAL REVIEW/AUDIT 830 FUNDING CODE NOT ON FILE 046 INTERNAL REVIEW/AUDIT 831 GROSS ADJ AMT IS ZERO 046 INTERNAL REVIEW/AUDIT 846 REPLCMT OVER 6-MO FILING LIMIT 046 INTERNAL REVIEW/AUDIT 873 INPATIENT READMISSION DETECTED 046 INTERNAL REVIEW/AUDIT 874 INPATIENT TRANSFER DETECTED 046 INTERNAL REVIEW/AUDIT 889 DEBIT RPL OR POS CREDIT CONFL 046 INTERNAL REVIEW/AUDIT 891 BASE RATE CHNG RSNS EXCEEDED 046 INTERNAL REVIEW/AUDIT 892 ON-SIZE ERROR 046 INTERNAL REVIEW/AUDIT 895 AMT TOO LARGE FOR SYSTEM 046 INTERNAL REVIEW/AUDIT 896 RELATED HX REC MAX EXCEEDED 046 INTERNAL REVIEW/AUDIT 898 RECORD OVERFLOW NO ACTION 046 INTERNAL REVIEW/AUDIT 899 MORE THAN 25 EXCEPTIONS 049 PENDING PROVIDER ACCREDITATION REVIEW 320 LAB PROV NOT CLIA CERTIFIED 050 203 PCUR PROV NBR REQD 310 REF/OTHER PROV NOT OUT HM PROV 315 PAY-TO PROVIDER NOT POS 321 PROVIDER INELIGIBLE FOR TRANSPLANT 396 TRTG/PROV NOT OUT OF HOME PROV 052 CLAIM WAITING FOR INTERNAL PROVIDER VERIFICATION. CLAIM WAITING FOR INTERNAL PROVIDER VERIFICATION. CLAIM WAITING FOR INTERNAL PROVIDER VERIFICATION. CLAIM WAITING FOR INTERNAL PROVIDER VERIFICATION. CLAIM WAITING FOR INTERNAL PROVIDER VERIFICATION. ENTITY NOT APPROVED 393 RECIP OR PROV TYPE INELIGIBLE 052 ENTITY NOT APPROVED 400 PAY-TO PRV NOT AUTH FOR PKG SV 054 DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE. DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE. DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE. DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE. DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE. DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE. DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE. Duplicate of a previously processed claim/line. 101 DUPLICATE/CONFLICT SAME PROV 102 DUPLICATE/CONFLICT DIFF PROV 103 POSSIBLE DUPLICATE OR CONFLICT 105 DUPLICATE INPATIENT/OUTPATIENT 108 NEW PATIENT VISIT PREV PAID 639 ASC DUPLICATE/CONFLICT 877 PHARM CLM DUPL W/I ONE DAY 926 TPL DENIAL INDICATES THIS IS A DUPLICATE CHARGE-RESUBMIT WITH A COPY OF THE ORIGINAL DENIAL. 005 EXTRACTION PREVIOUSLY PAID 056 DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE. AWAITING ELIGIBILITY DETERMINATION. 274 RECIP/COVERED DAYS CNFL 056 AWAITING ELIGIBILITY DETERMINATION. 714 CLAIM IN SUSPENSE MORE THAN 80 DAYS 050 050 050 050 054 054 054 054 054 054 054 054 7 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 056 AWAITING ELIGIBILITY DETERMINATION. 715 CLAIM IN SUSPENSE MORE THAN 23 DAYS. 065 Claim/line has been paid. 937 THIS CLAIM HAS PREVIOUSLY BEEN PAID; IT MIGHT HAVE BEEN PAID ZERO, PLEASE DO A REPLACEMENT CLAIM. 065 Claim/line has been paid. 945 MEDICARE HAS PAID THIS CLAIM IN FULL 084 SERVICE NOT AUTHORIZED 368 NUTRIT NOT COVERED BY QMB IN N 084 SERVICE NOT AUTHORIZED. 598 NOT ELIGIBLE FOR SPECIAL TRANS 084 SERVICE NOT AUTHORIZED 878 CRNA INCLUDED IN INPATIENT RAT 095 Requested additional information not received. 935 PROVIDER DID NOT RETURN REQUESTED DOCUMENTATION OF INSURANCE DENIAL (CCTAD) 097 233 HOSPICE RECIP INELIG FOR SERV 244 RECIP DOD AFTER CLM DOD 245 RECIP DOD PRIOR TO CLM DOD 246 RECIP NOT ELIG FOR SPMI CASE M 248 RECIP ID/RECIP DOB MISMATCH 249 RECIP ELIG PENDING LT 60 DAYS 250 RECIP NOT ON FILE LT 60 DAYS 252 RECIP INELIG FOR XOVER SERV 253 MAJ PROG DOES NOT COVER MCARE 257 RECIP UNDER REVW 261 RECIP ELIG PENDING GT 59 DAYS 271 RECIP INELIG FOR SERV 272 RECIP INELIG FOR PPHP 304 RECIP INELIG SERV MONTH 7,8,9 116 PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. PATIENT ELIGIBILITY NOT FOUND WITH ENTITY. CLAIM SUBMITTED TO INCORRECT PAYER. 237 MCARE IS ON RECIPIENT ELIG FIL 116 CLAIM SUBMITTED TO INCORRECT PAYER. 308 RECIP ENROL PPHP/PPHP UNMTCHD 122 708 SCREENING ANNUAL REVIEW NOT PRESENT 125 MISSING/INVALID DATA PREVENTS PAYER FROM PROCESSING CLAIM. Entity's name. 916 132 ENTITY'S MEDICAID PROVIDER ID. 120 RECIP NAME ON CLAIM DOES NOT MATCH NAME ON EOB PAY-TO PROV IS MIS OR INV 132 ENTITY'S MEDICAID PROVIDER ID. 122 TRTG PROV CHK DIGIT INVALID 132 ENTITY'S MEDICAID PROVIDER ID. 125 PAY-TO PROV CHK DIGIT INVALID 132 ENTITY'S MEDICAID PROVIDER ID. 133 ATTEND PROV CHK DIGIT INVALID 132 ENTITY'S MEDICAID PROVIDER ID. 134 ATTEND PROV NBR IS MIS OR INV 132 ENTITY'S MEDICAID PROVIDER ID. 135 TRTG PROV IS MIS OR INV 097 097 097 097 097 097 097 097 097 097 097 097 097 8 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 132 ENTITY'S MEDICAID PROVIDER ID. 154 PRESCR PROV IS MIS OR INV 132 ENTITY'S MEDICAID PROVIDER ID. 161 PRESCR CHK DIGIT INV 132 ENTITY'S MEDICAID PROVIDER ID. 205 REF/PRESCR/OTHER PROV NBR REQD 132 ENTITY'S MEDICAID PROVIDER ID. 287 TRTG PROV NOT AUTH FOR PROG 132 ENTITY'S MEDICAID PROVIDER ID. 288 REF/PRSC/OTHR PROV NOT ON FILE 132 ENTITY'S MEDICAID PROVIDER ID. 300 PAY-TO PROV NOT ON FILE 132 ENTITY'S MEDICAID PROVIDER ID. 301 TRTG PROV/CAT OF SERV CNFL 132 ENTITY'S MEDICAID PROVIDER ID. 302 ATTEND NBR NOT ON FILE 132 ENTITY'S MEDICAID PROVIDER ID. 405 PAY-TO PROV ENROL STAT - PEND 132 ENTITY'S MEDICAID PROVIDER ID 406 PAY-TO PROV ENROL STAT - TERM 132 ENTITY'S MEDICAID PROVIDER ID 407 PAY-TO PROV NOT AUTH MAJ PROG 132 ENTITY'S MEDICAID PROVIDER ID 409 PRESCR PROV TYPE INVALID 132 ENTITY'S MEDICAID PROVIDER ID 415 TRTG PROV NOT ON FILE 132 ENTITY'S MEDICAID PROVIDER ID 415 TRTG PROV ENROL STAT - PEND 132 ENTITY'S MEDICAID PROVIDER ID 416 TRTG PROV ENROL STAT - TERM 132 ENTITY'S MEDICAID PROVIDER ID. 418 PAY-TO PROV PRAC TYPE GRP DPND 132 ENTITY'S MEDICAID PROVIDER ID. 420 PAY-TO PROV ENROL AS NO-PAY 132 ENTITY'S MEDICAID PROVIDER ID. 421 TRTG PROV IS A GROUP PROV 132 ENTITY'S MEDICAID PROVIDER ID. 422 TRTG PROV NOT ENROLLED 132 ENTITY'S MEDICAID PROVIDER ID. 423 TRTG PROV NOT IN PAY-TO GROUP 132 ENTITY'S MEDICAID PROVIDER ID. 424 PAY-TO PROV NOT ENROLLED 132 ENTITY'S MEDICAID PROVIDER ID. 425 TRTG PROV TYPE/MOD CNFL 132 ENTITY'S MEDICAID PROVIDER ID. 426 PAY-TO PROV SWA NUM REQ 132 ENTITY'S MEDICAID PROVIDER ID. 427 PAY-TO/TRTG PROV BOTH INDIV 132 ENTITY'S MEDICAID PROVIDER ID. 616 REF PHYS MISSING ON CRNA CLAIM 158 ENTITY'S DATE OF BIRTH 130 RECIP DOB IS MIS OR INV 159 ENTITY'S DATE OF DEATH 622 DATE OF DEATH VS DOS 171 OTHER INSURANCE COVERAGE INFORMATION. 270 TPL RESOURCE REC MAY BE REQD 178 SUBMITTED CHARGES. 132 SUB CHRG IS MIS OR INV 181 HOSPITAL ROOM RATE 705 PRIVATE ROOM NOT VALID FOR PROVIDER 181 HOSPITAL(S) ROOM RATE 867 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 247 MCARE RETRO IS PRESENT 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 254 MCARE REJECT - TPL 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 262 TPL RESOURCE AVAIL BUT REJECTE 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 263 TPL RESOURCE AVAIL - PAY 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 264 TPL RESOURCE AVAIL - PAY/BILL 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 265 TPL RESOURCE AVAIL - SUSP 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 266 TPL TORT RESOURCE AVAIL - SUSP 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 267 TPL RESOURCE AVAIL - DENY 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 268 TPL TOO LOW NO COST AVOID ROOM AND BOARD RATE MIS OR INV 9 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 277 TPL INITIATED CCTAD PROCESSING 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 278 TPL ABSENT PARENT INDICATED 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 279 CCTAD AUTOMATICALLY GENERATED 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 280 TPL CVRG REQD FOR INPATIENT CL 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 281 TPL TOO LOW MULTI COST AVOID 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 283 MCARE ACT/DEN - NONENTITLED 182 ALLOWABLE/PAID FROM PRIMARY COVERAGE. 698 TPL RESOURCE SUSPENSE IND ON 182 Allowable/paid from primary coverage. 909 THE AMOUNT RECEIVED FROM OTHER SOURCES MUST BE ENTERED ON THE CLAIM FORM; INSURANCE PAYMENT REPORTS SHOULD ONLY BE ATTACHED AS REQUIRED IN THE MANUAL 187 DATE(S) OF SERVICE. 112 FDOS/LDOS NOT SAME MO/YR 187 DATE(S) OF SERVICE. 124 FDOS IS MIS OR INV 187 DATE(S) OF SERVICE. 126 FDOS AFTER LDOS 187 DATE(S) OF SERVICE. 127 LDOS AFTER JULIAN DATE 187 DATE(S) OF SERVICE. 155 LDOS IS MIS OR INV 187 DATE(S) OF SERVICE. 163 LI DOS OUTSIDE FROM/THRU DATES 187 DATE(S) OF SERVICE 317 IHS FDOS DON’T MATCH 187 DATE(S) OF SERVICE 611 IEP SPAN DATE CONFLICT 187 DATE(S) OF SERVICE. 655 FROM/THRU DATE NOT ALLOWED 187 Date(s) of service. 911 188 STATEMENT FROM-THROUGH DATES. 225 DOS ON MEDICARE EOB DOES NOT MATCH DOB ON CLAIM INVALID HOSPITAL TO FROM DATE 189 HOSPITAL ADMISSION DATE. 167 ADMIT DATE IS MIS OR INV 189 HOSPITAL ADMISSION DATE. 379 CHECK ADMISSION DATE FIELD 189 HOSPITAL ADMISSION DATE 701 191 DATE OF LAST MENSTRUAL PERIOD (LMP). 625 LTC ADMISSION DATE IS LATER THAN SERVICE START DATE LAST MENSTRUAL DTE MISSING/INV 216 DRUG INFORMATION. 326 DRUG NOT COVERED ON SERV DATE 216 DRUG INFORMATION. 327 DRUG LESS THAN EFFECTIVE 216 DRUG INFORMATION. 328 DRUG NOT IN FORMULARY 216 DRUG INFORMATION. 329 DRUG EXPIRED 216 DRUG INFORMATION. 333 DRUG COMPOUND 216 DRUG INFORMATION. 336 DRUG/SEX CNFL 216 DRUG INFORMATION. 337 DRUG/LA CNFL 216 DRUG INFORMATION. 338 DRUG QUANTITY LT MIN ALLOW 216 DRUG INFORMATION. 339 DRUG QUANTITY GT MAX ALLOW 216 DRUG INFORMATION. 340 DRUG/RECIP AGE LT MIN ALLOW 216 DRUG INFORMATION. 341 DRUG/RECIP AGE GT MAX ALLOW 216 DRUG INFORMATION. 342 DRUG EXCLUDED BY MINN 216 DRUG INFORMATION. 343 DRUG REQUIRES MANUAL REVW 216 DRUG INFORMATION. 344 DRUG NOT ALLOW FOR SERV DATES 216 DRUG INFORMATION. 346 DRUG UNIT DOSE CNFL 10 CodeDefinition Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 216 DRUG INFORMATION. 348 DRUG NOT COVERED 216 DRUG INFORMATION. 349 DRUG REQUIRES REVW 216 DRUG INFORMATION. 353 DRUG MAC OVERRIDE NOT REQD 216 DRUG INFORMATION. 357 DRUG SUPPLY LT MIN DAYS ALLOW 216 DRUG INFORMATION. 358 DRUG SUPPLY GT MAX DAYS ALLOW 216 DRUG INFORMATION. 359 DRUG/PROV UNIT DOSE CNFL 216 DRUG INFORMATION. 360 DRUG NOT ON FILE 216 DRUG INFORMATION 440 COMPOUND CODE 216 DRUG INFORMATION 443 COMPOUND LINE ITEMS 216 DRUG INFORMATION 447 COMPOUND RTE ADMIN 216 DRUG INFORMATION. 660 DUR-MAX-UTIL 216 DRUG INFORMATION. 661 DUR-MIN-UTIL 216 DRUG INFORMATION. 662 DUR-SAFE-DAYS 216 DRUG INFORMATION. 663 DUR-DRUG-DRUG 216 DRUG INFORMATION. 664 DUR-DRUG-DIAG 216 DRUG INFORMATION. 665 THERAPEUTIC DUPLICATION 216 DRUG INFORMATION. 666 GROUPER V15 VERIFICATION 216 DRUG INFORMATION. 667 DUR LOW DOSE IDENTIFIED 216 DRUG INFORMATION. 668 DUR HIGH DOSE IDENTIFIED 216 DRUG INFORMATION 880 REFILL NOT ALLOW 216 Drug information. 993 DRUG NAME AND/OR DOSAGE IS MISSING 218 NDC NUMBER. 152 DRUG CODE IS MISSING 219 PRESCRIPTION NUMBER 146 RX NBR IS MISSING 228 TYPE OF BILL FOR UB-92 CLAIM. 258 BILL TYPE INV FOR LTC CLAIM 228 TYPE OF BILL FOR UB-92 CLAIM. 637 CREDIT MEDICARE CLAIM 228 TYPE OF BILL FOR UB-92 CLAIM 870 BILL TYPE INVALID 229 HOSPITAL ADMISSION SOURCE. 114 ADMIT SOURCE INVALID 230 HOSPITAL ADMISSION HOUR. 111 ADMIT HOUR MUST BE PRESENT 231 HOSPITAL ADMISSION TYPE 147 ADMIT TYPE INVALID 233 HOSPITAL DISCHARGE HOUR. 224 DISCH HOUR IS MIS OR INV 234 PATIENT DISCHARGE STATUS. 188 PATIENT STATUS INVALID 237 UNITS OF DEDUCTIBLE BLOOD. 171 BLOOD DED IS MIS OR INV 238 576 MOTHER/NEWBORN SHOULD BE SEP 119 TOOTH SURFACE INVALID 361 TOOTH NBR REQD 362 TOOTH SURFACE REQD 244 SEPARATE CLAIM FOR MOTHER/BABY CHARGES. TOOTH NUMBERS, SURFACES, AND/OR, QUADRANTS INVOLVED. TOOTH NUMBERS, SURFACES, AND/OR, QUADRANTS INVOLVED. TOOTH NUMBERS, SURFACES, AND/OR, QUADRANTS INVOLVED. TOOTH NUMBER OR LETTER 868 TOOTH NBR INVALID 249 PLACE OF SERVICE. 150 PLACE OF SERV IS MIS OR INV 252 AUTHORIZATION/CERTIFICATION NUMBER. 209 252 AUTHORIZATION/CERTIFICATION NUMBER. 215 PRIOR/TREATMENT AUTHORIZATION SYSTEM INCONSISTENCY WAIVER SVC ON NON-WAIVER CLAIM 252 AUTHORIZATION/CERTIFICATION NUMBER 297 CERT DATE IS ZERO 252 AUTHORIZATION/CERTIFICATION NUMBER 298 CERT DATE GT 30 BEFORE ADMIT 252 AUTHORIZATION/CERTIFICATION NUMBER 299 CERT DATE GT 30 AFTER ADMIT 242 242 242 11 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 252 AUTHORIZATION/CERTIFICATION NUMBER. 378 SSO REQD 252 AUTHORIZATION/CERTIFICATION NUMBER. 384 PRENATAL HIGH RISK NOT AUTH 252 AUTHORIZATION/CERTIFICATION NUMBER. 388 SSO NOT ON FILE 252 AUTHORIZATION/CERTIFICATION NUMBER. 390 SSO RESOLUTION NOT APPROVED 252 AUTHORIZATION/CERTIFICATION NUMBER. 436 AUTH IS REQD 252 AUTHORIZATION/CERTIFICATION NUMBER 500 AUTH NOT ON FILE 252 AUTHORIZATION/CERTIFICATION NUMBER 501 AUTH IS PENDING 252 AUTHORIZATION/CERTIFICATION NUMBER 502 AUTH/RECIP CNFL 252 AUTHORIZATION/CERTIFICATION NUMBER 503 AUTH IS DENIED 252 AUTHORIZATION/CERTIFICATION NUMBER 504 AUTH/MOD CNFL 252 AUTHORIZATION/CERTIFICATION NUMBER 505 252 AUTHORIZATION/CERTIFICATION NUMBER 510 PA/SA NUMBER IS INVALID. IT MUST BE NUMERIC AUTH/PROV CNFL 252 AUTHORIZATION/CERTIFICATION NUMBER 511 AUTH/SVC CNFL 252 AUTHORIZATION/CERTIFICATION NUMBER 512 AUTH HEADER UNITS USED 252 AUTHORIZATION/CERTIFICATION NUMBER 513 AUTH SCH E/T IND CONFLICT 252 AUTHORIZATION/CERTIFICATION NUMBER 514 AUTH LI STATUS IS PENDING 252 AUTHORIZATION/CERTIFICATION NUMBER 515 AUTH TYPE MISMATCH 252 AUTHORIZATION/CERTIFICATION NUMBER 516 AUTH/CLM MSG CNFL 252 AUTHORIZATION/CERTIFICATION NUMBER 517 AUTH/CLM DIAG CNFL 252 AUTHORIZATION/CERTIFICATION NUMBER 518 AUTH LI STATUS IS DENIED 252 AUTHORIZATION/CERTIFICATION NUMBER 520 AUTH LI REQUIRES REVW 252 AUTHORIZATION/CERTIFICATION NUMBER. 540 AUTH FREQ CNFL WITH CLM 252 AUTHORIZATION/CERTIFICATION NUMBER. 600 CERT NBR IS MIS OR INV 252 AUTHORIZATION/CERTIFICATION NUMBER. 603 CERT NOT ON FILE 252 AUTHORIZATION/CERTIFICATION NUMBER. 604 AUTH/SVC CNFL - ADJUD 252 AUTHORIZATION/CERTIFICATION NUMBER. 605 REFER CLAIM IF MJR PGM E AND T 252 AUTHORIZATION/CERTIFICATION NUMBER. 606 AUTH/SVC DATE CNFL - ADJUD 252 AUTHORIZATION/CERTIFICATION NUMBER. 607 AUTH/MED SUPPLY CODE CNFL 12 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 252 AUTHORIZATION/CERTIFICATION NUMBER. 608 AUTH/TOOTH NUM CNFL 252 AUTHORIZATION/CERTIFICATION NUMBER. 609 AUTH/TOOTH SURF CNFL 252 AUTHORIZATION/CERTIFICATION NUMBER. 610 AUTH LI REQ REVW - 30 DAYS 252 AUTHORIZATION/CERTIFICATION NUMBER. 612 ICFMR SCREENING OLD OR MISS 252 AUTHORIZATION/CERTIFICATION NUMBER.AUTHORIZATION/CERTIFICATION NUMBER AUTHORIZATION/CERTIFICATION NUMBER. 613 ICFMR SCRNG TIMING 252 AUTHORIZATION/CERTIFICATION NUMBER.AUTHORIZATION/CERTIFICATION NUMBER AUTHORIZATION/CERTIFICATION NUMBER. 617 AUTH LI USED NO UNITS REMAIN 252 AUTHORIZATION/CERTIFICATION NUMBER.AUTHORIZATION/CERTIFICATION NUMBER AUTHORIZATION/CERTIFICATION NUMBER. 618 AUTH HEADER AMT USED - ADJUD 252 AUTHORIZATION/CERTIFICATION NUMBER 646 PA SA BKOUT NOT FND 252 AUTHORIZATION/CERTIFICATION NUMBER. 656 AUTH REQ IF GREATER THAN $400 252 AUTHORIZATION/CERTIFICATION NUMBER. 696 PA SA MST REC NTFND 252 AUTHORIZATION/CERTIFICATION NUMBER. 797 REPAIR > THAN $400.00 REQ P.A. 252 Authorization/certification number. 902 MEDICAL SUPPLY CLAIM USING MISCELLANEOUS CODE WITH SUBMITTED CHARGES OVER $400.00 MUST BE AUTHORIZED 252 AUTHORIZATION/CERTIFICATION NUMBER. 027 P.A. REQUIRED AFTER 2 MO. RENT 252 AUTHORIZATION/CERTIFICATION NUMBER. 028 P.A. REQUIRED AFTER 6 MO. RENT 252 AUTHORIZATION/CERTIFICATION NUMBER. 029 P.A. REQUIRED AFTER 3 MO. RENT 252 AUTHORIZATION/CERTIFICATION NUMBER. 030 P.A. REQUIRED AFTER 4 MO. RENT 252 AUTHORIZATION/CERTIFICATION NUMBER. 031 P.A. REQ IF GREATER THAN $100. 252 AUTHORIZATION/CERTIFICATION NUMBER. 050 CHGS IN EXCESS OF $100 REQ PA 255 DIAGNOSIS CODE. 240 1ST DIAG IS CD DIAG 255 DIAGNOSIS CODE. 332 DIAG CODE MISSING 255 DIAGNOSIS CODE 450 DIAG NOT ON FILE 255 DIAGNOSIS CODE 451 DIAG NOT COVERED 255 DIAGNOSIS CODE 453 DIAG REQUIRES REVW 255 DIAGNOSIS CODE 454 DIAG/AGE CNFL 255 DIAGNOSIS CODE 455 DIAG/SEX CNFL 255 DIAGNOSIS CODE 456 DIAGNOSIS NOT SPECIFIC 13 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 255 DIAGNOSIS CODE 488 ADM DIAG NOT ON FILE 255 DIAGNOSIS CODE 489 ADM DIAG/SEX CNFL 255 DIAGNOSIS CODE 492 ADM DIAG NOT SPECIFIC 255 DIAGNOSIS CODE 497 ADM DIAG NOT COVERED 255 DIAGNOSIS CODE 498 ADM DIAG REQUIRES REVW 255 DIAGNOSIS CODE 499 ADM DIAG/AGE CNFL 255 DIAGNOSIS CODE. 578 1ST DIAG CANNOT BEGIN WITH "E" 255 DIAGNOSIS CODE. 594 DIAG V57 W/O OTHER DIAG 255 DIAGNOSIS CODE. 596 DIAG RELATED CODE INVALID 255 DIAGNOSIS CODE. 597 LEVEL 1 DX CODE 769 255 DIAGNOSIS CODE. 599 PREMATURITY DX CODE CONFLICT 256 DRG CODE(S). 428 PRICING DATA NOT AVAILABLE 256 DRG CODE(S). 429 RELATIVE VALUE PRICING INACTIV 256 DRG CODE(S). 580 BASE PRICE MISSING ON ADMIT DA 256 DRG CODE(S). 581 INTERIM BLNG CNFL 256 DRG CODE(S). 582 DRG PRICING REC NOT FOUND 256 DRG CODE(S). 583 DRG RC 1 256 DRG CODE(S). 584 DRG RC 2 256 DRG CODE(S). 585 DRG RATE SPAN NOT FOUND 256 DRG CODE(S). 586 DRG REGROUPING FAILED 256 DRG CODE(S). 587 DRG RC 3 256 DRG CODE(S). 588 DRG RV/LOS MISSING 256 DRG CODE(S). 589 DRG RC 4 256 DRG CODE(S). 590 DRG RC 5 256 DRG CODE(S). 592 DRG RC 6 256 DRG CODE(S). 593 DRG RC 7 258 DAYS/UNITS FOR PROCEDURE/REVENUE CODE 394 PROC/FROM-THROUGH UNITS CNFL 258 DAYS/UNITS FOR PROCEDURE/REVENUE CODE. 519 SUB UNITS GREATER THAN ALLOWED 258 DAYS/UNITS FOR PROCEDURE/REVENUE CODE. 538 REV/FROM-THROUGH UNITS CNFL 259 FREQUENCY OF SERVICE. 139 LOS EXCEEDED FOR DIAG 259 FREQUENCY OF SERVICE. 002 ALLOWED ONCE PER LIFETIME 259 FREQUENCY OF SERVICE. 003 RCT-MORE THAN 1 MOLAR/DAY 259 FREQUENCY OF SERVICE. 007 1 RCT/TOOTH OR NO REIM ADD SUR 266 TRANS CLM W/O FROM-TO DEST 277 FACILITY POINT OF ORIGIN AND DESTINATION- 143 AMBULANCE. Paper claim. 997 279 Itemized claim. 921 THESE SERVICES MUST BE ITEMIZED 286 OTHER PAYER'S EXPLANATION OF BENEFITS/PAYMENT INFORMATION. Other payer's Explanation of Benefits/payment information. 242 MCARE REJECT - SERV NOT COVERE 933 SERVICE SHOULD BE BILLED TO INSURANCE COMPANY CURRENTLY IN EFFECT; INSURANCE INFORMATION ATTACHED TO CLAIM DOESN'T MATCH CURRENT TPL INFORMATION ; CONTACT EVS 298 Operative report. 980 306 Detailed description of service. 904 RESUBMIT CLAIM WITH A COPY OF THE OPERATIVE REPORT DESCRIPTION PROVIDED NOT SUFFICIENT 286 14 RESUBMIT CLAIM ON PAPER INVOICE Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 306 Detailed description of service. 914 DESCRIPTION OF SERVICE IS MISSING 306 DETAILED DESCRIPTION OF SERVICE. 051 DOCUMENTATION REQUIRED 337 153 NBR OF RIDERS IS MIS OR INV 149 INJURY DATE IS MIS OR INV 400 AMBULANCE CERTIFICATION/DOCUMENTATION. DATE OF ONSET/EXACERBATION OF ILLNESS/CONDITION. CLAIM IS OUT OF BALANCE. 118 MCARE CO-INS/DED NOT ALLOCATED 400 CLAIM IS OUT OF BALANCE. 140 PRIOR PAYMENTS CNFL 400 CLAIM IS OUT OF BALANCE. 160 TOTAL CLM CHRG CNFL 400 CLAIM IS OUT OF BALANCE 623 ADJUST AMT GT MA PAID AMT 400 CLAIM IS OUT OF BALANCE. 823 TPL AMT IS MIS OR INV 400 CLAIM IS OUT OF BALANCE. 825 NET CLM CHRG CNFL 401 SOURCE OF PAYMENT IS NOT VALID. 213 ONE PAYER CODE OF "D" REQD 421 MEDICAL REVIEW 323 ATTACHMENT/INFORMATION FOR SERVICE(S). 421 MEDICAL REVIEW ATTACHMENTS/INFORMATION FOR SERVICE(S). 671 ABORTION OPERATIVE RPT REQD 421 MEDICAL REVIEW ATTACHMENTS/INFORMATION FOR SERVICE(S). 675 HYSTERECTOMY FORM REQD 421 MEDICAL REVIEW ATTACHMENTS/INFORMATION FOR SERVICE(S). 692 TPL ATTACHMENT PRESENT REVIEW 421 MEDICAL REVIEW ATTACHMENTS/INFORMATION FOR SERVICE(S). 693 ATTACHMENT PRESENT 421 MEDICAL REVIEW ATTACHMENTS/INFORMATION FOR SERVICE(S). 694 ATTACHMENT PRESENT - TORT 421 MEDICAL REVIEW ATTACHMENTS/INFORMATION FOR SERVICE(S). 695 ATTACHMENT IND IS INVALID 421 MEDICAL REVIEW 826 ATTACHMENT/INFORMATION FOR SERVICE(S) ATTACHMENT PRESENT - PRICING 421 MEDICAL REVIEW 827 ATTACHMENT/INFORMATION FOR SERVICE(S) ATTACHMENT PRESENT - MEDICARE 433 232 HOSPICE PARTICIPATION REQ 448 COPY OF PATIENT REVOCATION OF HOSPICE BENEFITS. INVALID BILLING COMBINATION 106 MULTI VISITS-SAME DAY 448 INVALID BILLING COMBINATION 109 SURGERY FOLLOW-UP COVERS SERV 397 PROC REQUIRES ATTACH/DESCRIPT 448 INVALID BILLING COMBINATION 110 PROC COMBINATION INVALID 448 INVALID BILLING COMBINATION 116 SVC COMBINATION INVALID 448 INVALID BILLING COMBINATION 136 PROC/DIAG CNFL 448 INVALID BILLING COMBINATION 141 GENERIC CODE/DIAG CNFL 448 INVALID BILLING COMBINATION 220 TCN TO CREDIT/BILL TYPE CNFL 448 INVALID BILLING COMBINATION 229 HOSPICE/DOS CNFL 448 INVALID BILLING COMBINATION 230 LA/WAIVER CNFL 448 INVALID BILLING COMBINATION 231 DIAG/MAJ PROG CNFL 448 INVALID BILLING COMBINATION 234 LA/CAT OF SERV CNFL 15 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 448 INVALID BILLING COMBINATION 238 LA/DAW CNFL 448 INVALID BILLING COMBINATION 239 MAJ PROG/PLACE OF SERV CNFL 448 INVALID BILLING COMBINATION 273 PAY-TO PROV/CONTRACT NBR CNFL 448 INVALID BILLING COMBINATION 275 MAJ PROG/CAT OF SERV CNFL 448 INVALID BILLING COMBINATION 276 WAIVER PROG/SERV CNFL 448 INVALID BILLING COMBINATION 285 LA/TRTG PROV SPEC CNFL 448 INVALID BILLING COMBINATION 290 LA/COS CNFL FOR RTC-DD 448 INVALID BILLING COMBINATION 291 LA/COS CNFL FOR RTC-MH 448 INVALID BILLING COMBINATION 292 MAJ PROG/COS CNFL FOR RTC-DD 448 INVALID BILLING COMBINATION 293 MAJ PROG/COS CNFL FOR RTC-MH 448 INVALID BILLING COMBINATION 314 CAT OF SERV/AGE CNFL 448 INVALID BILLING COMBINATION 335 PLACE OF SERV/PROC/MOD INVALID 448 INVALID BILLING COMBINATION 355 DRUG/PROV TYPE INVALID 448 INVALID BILLING COMBINATION 356 UPC PROC/CLM PROC CNFL 448 INVALID BILLING COMBINATION 364 PROC/TOOTH NBR CNFL 448 INVALID BILLING COMBINATION 365 PROC/PLACE OF SERV CNFL 448 INVALID BILLING COMBINATION 366 PROC/TRTG PROV SPEC MISMATCH 448 INVALID BILLING COMBINATION 367 PROC/TRTG PROV TYPE CNFL 448 INVALID BILLING COMBINATION 369 CONSECUTIVE DAY/UNITS CNFL 448 INVALID BILLING COMBINATION 370 PAY-TO-PROV/CLAIM TYPE CNFL 448 INVALID BILLING COMBINATION 372 PROC/CLM TYPE CNFL 448 INVALID BILLING COMBINATION 373 PEDIATRIC ADD REQ SPLIT BILL 448 INVALID BILLING COMBINATION 374 TRTG PROV/PLACE OF SERV CNFL 448 INVALID BILLING COMBINATION 375 PROC/LA CNFL 448 INVALID BILLING COMBINATION 387 TRTG PROV SPEC/MOD CNFL 448 INVALID BILLING COMBINATION 391 SSO/RECIP ID CNFL 448 INVALID BILLING COMBINATION 392 SSO/PROV NUM CNFL 448 INVALID BILLING COMBINATION 395 PROC/CONSECUTIVE-DAY CNFL 448 INVALID BILLING COMBINATION 399 CODING ERROR ON NEWBORN CLAIM 448 INVALID BILLING COMBINATION 401 TRTG PROV TYPE/MAJ PROG CNFL 448 INVALID BILLING COMBINATION. 432 PROC/DIAG SEX CNFL W/RECIP SEX 448 INVALID BILLING COMBINATION. 577 ASC SERV BLNG INCONSISTENT 448 INVALID BILLING COMBINATION 602 INDIAN HS CONFL W DENIED LINES 448 INVALID BILLING COMBINATION 614 448 INVALID BILLING COMBINATION 626 OUTPATIENT OBSERVATION CONFLICTS SAME DAY REV CODE/VALUE CODE CONFLICT 448 INVALID BILLING COMBINATION 629 MODIFIER CLAIM TYPE CONFLICT 448 INVALID BILLING COMBINATION 647 PROC CODE/TOOTH SURFACE CNFLT 448 INVALID BILLING COMBINATION. 673 REPL/CLAIM TYPE CNFL 448 INVALID BILLING COMBINATION 712 448 INVALID BILLING COMBINATION 713 448 INVALID BILLING COMBINATION. 790 COVERED AND NON-COVERED DAYS ON THE SAME INVOICE. MEDICARE CARRIER WITH COVERED AND NON-COVERED DAYS PROC/DIAG CONFLICT 448 INVALID BILLING COMBINATION. 820 VACCINE ADMINISTRATION CONFLICT 448 INVALID BILLING COMBINATION 866 SUB CHARGE/SUB RATE CNFL 448 879 SWING BED LOS IS > 40 DAYS 448 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. INVALID BILLING COMBINATIOIN 881 HOSPICE SERV CNFL ON SAME DAY 448 INVALID BILLING COMBINATION 006 PROC CODE IN CONFLICT W EXTRAC 16 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 448 INVALID BILLING COMBINATION 011 DENTAL PROC CODES ARE SAME DAY 448 INVALID BILLING COMBINATION 022 AEROSOL COMP CNFLT WITH NEB CO 448 INVALID BILLING COMBINATION 056 PROC CODES CONFLICT SAME DAY 448 INVALID BILLING COMBINATION 058 HOSPICE PROC CODES/SAME DAY 448 INVALID BILLING COMBINATION 060 PODIATRY PROC CODE/VISIT CODE 448 INVALID BILLING COMBINATION 061 SURG LUB INCL IN CATH TRAY 448 INVALID BILLING COMBINATION 067 MH SERV CONFLICT DAY TX 448 INVALID BILLING COMBINATION 070 908 & E/M SAME DAY NOT COVERED 448 INVALID BILLING COMBINATION 096 LAB PROCEDURE CONFLICT 450 AWAITING SPENDDOWN DETERMINATION. 640 SPDWN REDUCED BY REIMB AMT 450 AWAITING SPENDDOWN DETERMINATION. 641 SPENDDOWN SYSTEM ERROR* 450 AWAITING SPENDDOWN DETERMINATION. 642 FDOS LT SPDWN SATIS DATE 450 AWAITING SPENDDOWN DETERMINATION. 651 SPNDWN BKOUT NT FND 450 AWAITING SPENDDOWN DETERMINATION. 838 IND HS CLAIM WITH SPENDDOWN 453 117 MODIFIER INVALID 322 PROC CODE DISCONTINUED 324 MOD COMBINATION INVALID 334 MODIFIER REQUIRES MANUAL PRICING 363 PROCEDURE MODIFIER CONFLICT 376 PROC REQUIRES MODIFIER 634 INVALID MODIFIER ON C&TC 454 PROCEDURE CODE MODIFIER(S) FOR SERVICES(S) RENDERED. PROCEDURE CODE MODIFIER(S) FOR SERVICES(S) RENDERED. PROCEDURE CODE MODIFIER(S) FOR SERVICES(S) RENDERED. PROCEDURE CODE MODIFIER(S) FOR SERVICES(S) RENDERED. PROCEDURE CODE MODIFIER(S) FOR SERVICES(S) RENDERED. PROCEDURE CODE MODIFIER(S) FOR SERVICES(S) RENDERED. PROCEDURE CODE MODIFIER(S) FOR SERVICES(S) RENDERED. PROCEDURE CODE FOR SERVICES RENDERED. 172 PROC MISSING 454 PROCEDURE CODE FOR SERVICES RENDERED. 382 DTH PROV BILLED WRONG PROC 454 PROCEDURE CODE FOR SERVICES RENDERED. 430 PROC NOT ON FILE 454 PROCEDURE CODE FOR SERVICES RENDERED. 431 PROC NOT COVERED 454 PROCEDURE CODE FOR SERVICES RENDERED. 433 SUSP SERV OR BUNDLED SERVICE 454 PROCEDURE CODE FOR SERVICES RENDERED. 437 PROC NOT COVERED FOR SERV DATE 454 PROCEDURE CODE FOR SERVICES RENDERED. 439 PROC NOT ALLOW FOR SERV DATE 454 PROCEDURE CODE FOR SERVICES RENDERED. 560 OTHER SURGICAL PROCEDURE NOT ON FILE 454 PROCEDURE CODE FOR SERVICES RENDERED. 561 OTHER SURGICAL PROC NOT COVERED 454 PROCEDURE CODE FOR SERVICES RENDERED. 563 OTHER SURG PROC REQUIRES REVIEW 454 PROCEDURE CODE FOR SERVICES RENDERED. 564 OTHER SURGICAL PROC AGE CONFLICT 453 453 453 453 453 453 17 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 454 PROCEDURE CODE FOR SERVICES RENDERED. 565 OTHER SURGICAL PROC SEX CONFLICT 454 PROCEDURE CODE FOR SERVICES RENDERED. 566 OTHER SURG PROC REQUIRES AUTH 455 REVENUE CODE FOR SERVICES RENDERED. 148 REV IS MIS OR INV 455 REVENUE CODE FOR SERVICES RENDERED. 173 REV INVALID FOR HOSPICE 455 REVENUE CODE FOR SERVICES RENDERED. 347 REV NOT ON FILE 455 REVENUE CODE FOR SERVICE RENDERER 531 REV/CONSECUTIVE-DAY CNFL 455 REVENUE CODE FOR SERVICE RENDERER 533 REV/AGE CNFL 455 REVENUE CODE FOR SERVICE RENDERER 535 REV/DIAG SEX CNFL W/RECIP SEX 455 REVENUE CODE FOR SERVICE RENDERER 536 REV REQUIRES MANUAL REVW 455 REVENUE CODE FOR SERVICE RENDERER 539 REV/TRTG PROV SPEC MISMATCH 455 REVENUE CODE FOR SERVICE RENDERER 541 REV NOT ALLOW FOR SERV DATE 455 REVENUE CODE FOR SERVICE RENDERER 542 REV REQUIRES DIAG 455 REVENUE CODE FOR SERVICE RENDERER 544 REV NOT COVERED FOR SERV DATES 455 REVENUE CODE FOR SERVICE RENDERER 545 REV NOT COVERED 455 REVENUE CODE FOR SERVICE RENDERER 546 REV/TRTG PROV TYPE CNFL 455 REVENUE CODE FOR SERVICE RENDERER 549 REV REQUIRES REVW 456 COVERED DAY(S). 182 COVERED DAYS IS MIS OR INV 456 COVERED DAY(S). 183 COVERED/NONCOVERED DAYS CNFL 456 COVERED DAY(S). 221 COVERED DAYS NE REV DAYS 457 NON-COVERED DAY(S). 206 NON-COVERED CHRG CNFL 458 COINSURANCE DAY(S).. 709 COINSURANCE DAYS INVALID 458 COINSURANCE DAY(S).. 711 460 NUBC CONDITION CODE(S). 181 COINSURANCE DAYS ENTERED ON NONMEDICARE CLAIM CONDITION CODE(S) INVALID 461 NUBC OCCURRENCE CODE(S) AND DATE(S). 210 OCCUR CODE INVALID 461 NUBC OCCURRENCE CODE(S) AND DATE(S). 211 OCCUR CODE DATE MIS OR INV 462 137 1ST OCCUR SPAN DATES INV 138 2ND OCCUR SPAN DATES INV 185 OCC SPAN CODE OF 80 OR 74 REQ 208 OCCUR SPAN DATE MIS OR INV 212 OCCUR SPAN CODE INVALID 463 NUBC OCCURRENCE SPAN CODE(S) AND DATE(S). NUBC OCCURRENCE SPAN CODE(S) AND DATE(S). NUBC OCCURRENCE SPAN CODE(S) AND DATE(S). NUBC OCCURRENCE SPAN CODE(S) AD DATE(S). NUBC OCCURRENCE SPAN CODE(S) AD DATE(S). NUBC VALUE CODE(S) AND/OR AMOUNT(S). 222 VALUE AMT IS MIS OR INV 463 NUBC VALUE CODE(S) AND/OR AMOUNT(S). 223 VALUE CODE INVALID 465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S) 190 RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) 191 RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) 195 RENDERED. 462 462 462 462 465 465 18 PRINC SURG PROC STAY CNFL OTHER SURG PROC STAY CONFLICE INVALID ATTACHMENT DT Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 465 196 SURG PROC MISSING 197 PRINCIPLE SURGICAL DATE MISSING 198 OTHER SURGICAL DATE MISSING 354 ICD-9 PROCEDURE CODE MISSING 550 551 PRINCIPLE SURGICAL PROCEDURE NOT ON FILE PRINCIPLE SURGICAL PROC NOT COVERED 553 PRINCIPLE SURG PROC REQUIRES REVIEW 554 PRINCIPLE SURG PROC/AGE CNFL 555 PRINCIPLE SURG PROC SEX CONFLICT 556 PRINCIPLE SURG PROC REQUIRES AUTH 812 435 PRINCIPLE SURGICAL PROC ADMIT DATE CONFLICT OTHER SURGICAL PROC ADMIT DATE CONFLICT PROC/SEX CNFL 434 PROC/AGE CNFL 475 PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PRINCIPLE PROCEDURE CODE FOR SERVICE(S) RENDERED. PROCEDURE CODE AND PATIENT GENDER MISMATCH. PROCEDURE CODE NOT VALID FOR PATIENT AGE. Procedure code not valid for patient age. 591 C&TC CLAIM RECIP AGE > 20 476 MISSING OR INVALID UNITS OF SERVICE. 186 HOSPICE TOT UNITS GT TOT DAYS 476 MISSING OR INVALID UNITS OF SERVICE. 189 SUB UNITS OF SERV MIS OR INV 476 MISSING OR INVALID UNITS OF SERVICE. 619 CPI CLM MAX UNTS 476 MISSING OR INVALID UNITS OF SERVICE. 620 CPI GPR 2ND LINE EXC MAX UNITS 479 OTHER CARRIER PAYER ID IS MISSING OR INVALID. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. 217 PAYER CODE INVALID 107 RX EXCEEDS 12 MONTHS 295 BASE RATE EXCEEDS LIMIT 389 C&TC OUTREACH CAP EXCEEDED 632 AUTH LIMIT REACHED - DD WAIVER 650 BENEFITS LIMITS EXHAUSTED 681 INPATIENT PER DAY LIMIT 783 HBMHS LIMIT IS 48 HR PER 6 MO 784 MENT HLTH SESSION 5 DAY SPACE 785 INDIV PSYCH 10 DAY SPACING 786 DENTAL LIMIT OF 4/12 MOS. 465 465 465 465 465 465 465 465 465 465 465 474 475 483 483 483 483 483 483 483 483 483 483 813 19 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 483 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD.MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD.MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. 787 NUTRITION PROD LIMIT EXCEEDED 483 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. 788 P.T. PROC EXCEEDS 1 HR/DAY 789 DENTAL PROC/OFF VISIT SAME DAY 791 IND HS ENCOUNTER LIMIT 792 H.A. REPAIR SERV EXCEEDS LIMIT 793 EVAL EXCEEDS 3 PER CAL. YR. 795 UNITS EXCEED 23 PER CAL MO 796 DTH PILOT LIMIT EXCEEDED 799 OUTPAT HOSPITAL LIM 001 PROPHY, FLUORIDE, 1/180 DAYS 004 ONE SEALANT ALLOWED PER 5 YRS. 008 DENTAL PROC WITHIN 5 YRS 009 DENTAL PROCS WITHIN 1 YR 010 PERIAPICALS, 6 PER 12 MONTHS 012 SERVICE EXCEEDS MONTHLY ALLOW 013 CW-TCM 1/MO 014 CHIRO VISITS EXCEED 6/MONTH 015 RELINE OR REBASE WITHIN 3 YRS. 016 MED TRANS EXCEEDS 6/CAL MO 017 NUTRITIONAL CONSULT. 1/CAL. YR 018 NUTRIT CONSULT 2 FOLL-UP/CAL Y 019 EXCEEDS 6 UNITS PER CAL. YR. 020 EXCEEDS 4 UNITS PER CAL. YR. 021 EXCEEDS 36 UNITS PER CAL. YR. 023 SERVICE ALLOWED ONCE IN 3 YRS 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 20 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 483 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. 024 SERVICE ALLOWED ONCE IN 4 YRS 025 SERVICE ALLOWED ONCE/5 YRS 026 EXCEEDS 16 UNITS PER CAL YR 032 AUD SPEECH OR H.A. SERV 1/CAL-NU 033 EXCEEDS 2 UNITS PER CAL. YR. 034 O.T EVAL EXCEEDS 6/CAL. YR. 035 O.T. CONSULT EXCEEDS 4/CAL. YR 036 O.T. SUPP EXCEEDS MAX/CAL YR 037 EXCEEDS 40 UNITS/CAL YR 038 SERVICE ALLOWED ONCE/CAL. YR. 039 MAX UNITS PER DAY = 4 040 EXCEEDS 8 UNITS PER CAL YR 041 PT TEST OR AUD. LIMIT 2/CAL YR 042 P.T. ROM EXCEEDS 12/CAL YR 043 BREAST PUMP RR EXCEEDS ALLOW. 044 SERVICE EXCEEDS YEARLY LIMIT 045 EXCEEDS LIMIT OF 2 PER CAL YR. 046 H.A. CHECK EXCEEDS 4/CAL YR 047 MAX UNITS PER DAY = 2 048 1 YR PROC CODE EXCEEDS $ LIMIT 049 POD SERV EXCEEDS ONCE/60 DAYS 052 ACUPUNCTURE, LIMIT EXCEEDED 053 DENTAL PROC LIMIT EXCEEDED 054 LIMIT EXCEEDED 055 HRG AID SERV EXCEEDS 1/CAL YR 057 MAX UNITS = 47 059 MAX UNITS PER DAY = 24 062 SERVICE ALLOWED ONCE IN 2 YRS 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 21 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 483 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. 063 1 UNIT ALLOWED/30 DAYS 064 PRENATAL INIT EXCEEDS LIMIT 065 MAX UNITS PER CAL MO = 1 066 MAX UNITS PER YEAR = 13 068 IEP THERAPY EVAL - 6 UNITS/DAY 069 IEP SERV EXCEEDS DAILY LIMIT 071 DTH HOURLY SERV LIMIT EXCEEDED 072 SPMI LIMIT - 1 PROVIDER/60 DAY 073 MULTIFAM GROUP PSYCH 20 HR/YR 074 GRP PSYCH 6 UNIT/WK 1 PRV ONLY 075 NEUROPSYCH CONSULT 20/78 YEAR 076 HBMHS SKILLS TRAINING 192 HR 077 EXPLAIN/FINDINGS 4 HOURS/YR 078 NEUROPSYCH TESTING 15 HR/YEAR 079 PASARR DAILY OR CAL YR LIMIT 080 10 DAY SPACE BETWEEN SERVICES 081 INDIV/FAMILY PSYCH 5 DAY SPACE 082 PSYCH TESTNG LIMIT 32 UNITS/YR 083 DIFFERENT MH MODE 5 DAYS APART 084 MED MGMT LIMIT IS ONCE/7 DAYS 085 DAY TX LIMIT 3 UNIT/DAY 390 YR 086 TSFC BENEFITS EXHAUSTED 087 FCSS BENEFITS EXHAUSTED 088 HBMHS TRAVEL TIME 128 HR/6 MO 089 COG RETRN 4 HR/DAY 390 HR/YR 090 SPMI OUT-OF-CTY TRAV 8 HR/DAY 091 5 DAY SPACING / DIFF MH PROV 092 SPMI EXCEEDS 10 HR/MO LIMIT 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 483 22 Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003 Status Code Status Description EOB CodeDefinition 483 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD. 093 SPMI TELEPHONE EXCEEDS 3 HR/MO 094 DIAG ASSESS 16 UNITS/CAL YEAR 095 MED MGMT LIMIT IS 52 UNITS/YR 097 MH-TCM LIMIT EXCEEDED 483 483 483 23
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File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.4 Linearized : No Create Date : 2003:08:15 11:02:40Z Subject : HIPAA Status Code to DHS EOB Code Crosswalk Keywords : crosswalk, hipaa, status, code, eob, benefit, dhs, ra, remittance, advice Modify Date : 2003:12:01 15:13:42-06:00 Page Count : 23 Creation Date : 2003:08:15 11:02:40Z Author : MN DHS Health Care Provider Relations Producer : Acrobat PDFWriter 5.0 for Windows NT Mod Date : 2003:12:01 15:13:42-06:00 Metadata Date : 2003:12:01 15:13:42-06:00 Title : HIPAA Status Code to DHS EOB Code Crosswalk Creator : MN DHS Health Care Provider Relations Description : HIPAA Status Code to DHS EOB Code Crosswalk Has XFA : NoEXIF Metadata provided by EXIF.tools