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



Source Exif Data:
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                         : No
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