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, 199-
200, 216, 218-219,
226, 228, 235, 243,
282, 371, 441-442,
444, 448-449, 452,
457-487, 490-491, 493-
496, 506-509, 521-
530, 534, 537, 552,
557-559, 562, 567-
571, 573-575, 579,
653, 697, 703-704,
706, 710, 716, 721-
768, 800-811, 814-
819, 821-822, 832,
841, 849, 851-852,
860-865, 869, 882-
886, 893-894, 897
EOB CODE NOT USED
001 192 INVD CONSV BEG END DT
001 900 CLAIM LINE IN PROCESS
001 901 STERILIZATION FORM DOS NOT MEET
FEDERAL REQUIREMENTS
001 905 THIS CLAIM WAS DENIED BY MEDICAL
ASSISTANCE CONSULTANTS
001 906 MA DOES NOT COVER REDUCTIONS BY
MEDICARE
001 907 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 TPL COV IS PRIMARY-MUST FOLLOW PLAN
RULES
001 919 OVER YEAR OLD. DOES NOT MEET PAYMENT
CRITERIA
001 920 DOLLAR AMOUNT ON CLAIM DOES NOT
MATCH DOLLAR AMOUNT ON MEDICARE EOB
001 922 SERVICE ON CLAIM DOES NOT MATCH
SERVICE ON MEDICARE EOMB.
001 923
MEDICARE CLAIM PAYMENT DATE IS MISSING
FROM EOB; RESUBMIT FULL EOMB
001 924 REQ FORMS FOR ABORTION ARE MISSING OR
INCOMPLETE
001 925 MEDICARE EOB INFO DOES NOT MATCH
CLAIM INFO
001 927 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 THE DOCUMENTATION PROVIDED DOES NOT
MEET CRITERIA FOR PAYMENT
001 931 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 PROVIDER IS NOT ENROLLED TO PERFORM
THIS SERVICE
001 974 RESUBMIT CLAIM WITH MANUFACTURER'S
STATEMENT
002 MORE DETAILED INFORMATION IN LETTER. 648 CCTAD
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 B & C LEAVE DAYS NOT ALLOWED/
OCCUPANCY RATE.
009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 707 BOARD AND CARE CANNOT BE BILLED IN
MONTH OF SERV
009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 717 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 LTC HOSPITAL LKEAVE EXCEEDS 18
CONSECUTIVE DAYS
009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 720
LTC PAID PLUS CLAIMED COINSURANCE DAYS
EXCEED ANNUAL MAXIMUM
009 NO PAYMENT WILL BE MADE FOR THIS CLAIM. 845 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 PROVIDER REQUESTED CLAIM OR LINE BE
DENIED
009 No payment will be made for this claim. 912 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 MEDICARE CARRIER WITHOUT PRIOR PAY OR
COINSURANCE
021 MISSING OR INVALID INFORMATION 170 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 FOLLOW UP CALC ERROR (DATE
CONVERSION)
046 INTERNAL REVIEW/AUDIT 325 TRAUMA/ACCIDENT CLM
046 412 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 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 CLAIM WAITING FOR INTERNAL PROVIDER
VERIFICATION.
203 PCUR PROV NBR REQD
050 CLAIM WAITING FOR INTERNAL PROVIDER
VERIFICATION.
310
REF/OTHER PROV NOT OUT HM PROV
050 CLAIM WAITING FOR INTERNAL PROVIDER
VERIFICATION.
315 PAY-TO PROVIDER NOT POS
050 CLAIM WAITING FOR INTERNAL PROVIDER
VERIFICATION.
321 PROVIDER INELIGIBLE FOR TRANSPLANT
050 CLAIM WAITING FOR INTERNAL PROVIDER
VERIFICATION.
396
TRTG/PROV NOT OUT OF HOME PROV
052 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.
101 DUPLICATE/CONFLICT SAME PROV
054 DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
102 DUPLICATE/CONFLICT DIFF PROV
054 DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
103 POSSIBLE DUPLICATE OR CONFLICT
054 DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
105
DUPLICATE INPATIENT/OUTPATIENT
054 DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
108 NEW PATIENT VISIT PREV PAID
054 DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
639 ASC DUPLICATE/CONFLICT
054 DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
877 PHARM CLM DUPL W/I ONE DAY
054 Duplicate of a previously processed claim/line. 926 TPL DENIAL INDICATES THIS IS A DUPLICATE
CHARGE-RESUBMIT WITH A COPY OF THE
ORIGINAL DENIAL.
054 DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
005 EXTRACTION PREVIOUSLY PAID
056 AWAITING ELIGIBILITY DETERMINATION. 274 RECIP/COVERED DAYS CNFL
056 AWAITING ELIGIBILITY DETERMINATION. 714 CLAIM IN SUSPENSE MORE THAN 80 DAYS
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 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
233 HOSPICE RECIP INELIG FOR SERV
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
244 RECIP DOD AFTER CLM DOD
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
245 RECIP DOD PRIOR TO CLM DOD
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
246 RECIP NOT ELIG FOR SPMI CASE M
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
248 RECIP ID/RECIP DOB MISMATCH
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
249 RECIP ELIG PENDING LT 60 DAYS
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
250 RECIP NOT ON FILE LT 60 DAYS
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
252 RECIP INELIG FOR XOVER SERV
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
253
MAJ PROG DOES NOT COVER MCARE
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
257 RECIP UNDER REVW
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
261 RECIP ELIG PENDING GT 59 DAYS
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
271 RECIP INELIG FOR SERV
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
272 RECIP INELIG FOR PPHP
097 PATIENT ELIGIBILITY NOT FOUND WITH
ENTITY.
304 RECIP INELIG SERV MONTH 7,8,9
116 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 MISSING/INVALID DATA PREVENTS PAYER
FROM PROCESSING CLAIM.
708 SCREENING ANNUAL REVIEW NOT PRESENT
125 Entity's name. 916 RECIP NAME ON CLAIM DOES NOT MATCH
NAME ON EOB
132 ENTITY'S MEDICAID PROVIDER ID. 120 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
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
ROOM AND BOARD RATE MIS OR INV
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
9
Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003
Status
Code
Status Description EOB CodeDefinition
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 DOS ON MEDICARE EOB DOES NOT MATCH
DOB ON CLAIM
188 STATEMENT FROM-THROUGH DATES. 225 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 LTC ADMISSION DATE IS LATER THAN
SERVICE START DATE
191 DATE OF LAST MENSTRUAL PERIOD (LMP). 625 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
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 SEPARATE CLAIM FOR MOTHER/BABY
CHARGES.
576
MOTHER/NEWBORN SHOULD BE SEP
242 TOOTH NUMBERS, SURFACES, AND/OR,
QUADRANTS INVOLVED.
119 TOOTH SURFACE INVALID
242 TOOTH NUMBERS, SURFACES, AND/OR,
QUADRANTS INVOLVED.
361 TOOTH NBR REQD
242 TOOTH NUMBERS, SURFACES, AND/OR,
QUADRANTS INVOLVED.
362 TOOTH SURFACE REQD
244 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 PRIOR/TREATMENT AUTHORIZATION SYSTEM
INCONSISTENCY
252 AUTHORIZATION/CERTIFICATION NUMBER. 215
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
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 PA/SA NUMBER IS INVALID. IT MUST BE
NUMERIC
252 AUTHORIZATION/CERTIFICATION NUMBER 510 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
FACILITY POINT OF ORIGIN AND DESTINATION-
AMBULANCE.
143 TRANS CLM W/O FROM-TO DEST
277 Paper claim. 997 RESUBMIT CLAIM ON PAPER INVOICE
279 Itemized claim. 921 THESE SERVICES MUST BE ITEMIZED
286 OTHER PAYER'S EXPLANATION OF
BENEFITS/PAYMENT INFORMATION.
242 MCARE REJECT - SERV NOT COVERE
286 Other payer's Explanation of Benefits/payment
information.
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 RESUBMIT CLAIM WITH A COPY OF THE
OPERATIVE REPORT
306 Detailed description of service. 904 DESCRIPTION PROVIDED NOT SUFFICIENT
14
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 AMBULANCE
CERTIFICATION/DOCUMENTATION.
153 NBR OF RIDERS IS MIS OR INV
397 DATE OF ONSET/EXACERBATION OF
ILLNESS/CONDITION.
149 INJURY DATE IS MIS OR INV
400 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
ATTACHMENT/INFORMATION FOR SERVICE(S).
323 PROC REQUIRES ATTACH/DESCRIPT
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
ATTACHMENT/INFORMATION FOR SERVICE(S)
826 ATTACHMENT PRESENT - PRICING
421 MEDICAL REVIEW
ATTACHMENT/INFORMATION FOR SERVICE(S)
827
ATTACHMENT PRESENT - MEDICARE
433 COPY OF PATIENT REVOCATION OF HOSPICE
BENEFITS.
232 HOSPICE PARTICIPATION REQ
448 INVALID BILLING COMBINATION 106 MULTI VISITS-SAME DAY
448 INVALID BILLING COMBINATION 109
SURGERY FOLLOW-UP COVERS SERV
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
OUTPATIENT OBSERVATION CONFLICTS SAME
DAY
448 INVALID BILLING COMBINATION 626 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 COVERED AND NON-COVERED DAYS ON THE
SAME INVOICE.
448 INVALID BILLING COMBINATION 713 MEDICARE CARRIER WITH COVERED AND
NON-COVERED DAYS
448 INVALID BILLING COMBINATION. 790 PROC/DIAG CONFLICT
448 INVALID BILLING COMBINATION. 820 VACCINE ADMINISTRATION CONFLICT
448 INVALID BILLING COMBINATION 866 SUB CHARGE/SUB RATE CNFL
448 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
879 SWING BED LOS IS > 40 DAYS
448 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 PROCEDURE CODE MODIFIER(S) FOR
SERVICES(S) RENDERED.
117 MODIFIER INVALID
453 PROCEDURE CODE MODIFIER(S) FOR
SERVICES(S) RENDERED.
322 PROC CODE DISCONTINUED
453 PROCEDURE CODE MODIFIER(S) FOR
SERVICES(S) RENDERED.
324 MOD COMBINATION INVALID
453 PROCEDURE CODE MODIFIER(S) FOR
SERVICES(S) RENDERED.
334 MODIFIER REQUIRES MANUAL PRICING
453 PROCEDURE CODE MODIFIER(S) FOR
SERVICES(S) RENDERED.
363 PROCEDURE MODIFIER CONFLICT
453 PROCEDURE CODE MODIFIER(S) FOR
SERVICES(S) RENDERED.
376 PROC REQUIRES MODIFIER
453 PROCEDURE CODE MODIFIER(S) FOR
SERVICES(S) RENDERED.
634 INVALID MODIFIER ON C&TC
454 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
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 COINSURANCE DAYS ENTERED ON NON-
MEDICARE CLAIM
460 NUBC CONDITION CODE(S). 181 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 NUBC OCCURRENCE SPAN CODE(S) AND
DATE(S).
137 1ST OCCUR SPAN DATES INV
462 NUBC OCCURRENCE SPAN CODE(S) AND
DATE(S).
138 2ND OCCUR SPAN DATES INV
462 NUBC OCCURRENCE SPAN CODE(S) AND
DATE(S).
185 OCC SPAN CODE OF 80 OR 74 REQ
462 NUBC OCCURRENCE SPAN CODE(S) AD
DATE(S).
208 OCCUR SPAN DATE MIS OR INV
462 NUBC OCCURRENCE SPAN CODE(S) AD
DATE(S).
212 OCCUR SPAN CODE INVALID
463 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)
RENDERED.
190 PRINC SURG PROC STAY CNFL
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
191 OTHER SURG PROC STAY CONFLICE
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
195 INVALID ATTACHMENT DT
18
Attachment E - HIPAA Status Codes to DHS EOB Code Crosswalk - December 1, 2003
Status
Code
Status Description EOB CodeDefinition
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
196 SURG PROC MISSING
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
197 PRINCIPLE SURGICAL DATE MISSING
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
198 OTHER SURGICAL DATE MISSING
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
354 ICD-9 PROCEDURE CODE MISSING
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
550 PRINCIPLE SURGICAL PROCEDURE NOT ON
FILE
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
551 PRINCIPLE SURGICAL PROC NOT COVERED
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
553 PRINCIPLE SURG PROC REQUIRES REVIEW
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
554 PRINCIPLE SURG PROC/AGE CNFL
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
555 PRINCIPLE SURG PROC SEX CONFLICT
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
556 PRINCIPLE SURG PROC REQUIRES AUTH
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
812 PRINCIPLE SURGICAL PROC ADMIT DATE
CONFLICT
465 PRINCIPLE PROCEDURE CODE FOR SERVICE(S)
RENDERED.
813 OTHER SURGICAL PROC ADMIT DATE
CONFLICT
474 PROCEDURE CODE AND PATIENT GENDER
MISMATCH.
435 PROC/SEX CNFL
475 PROCEDURE CODE NOT VALID FOR PATIENT
AGE.
434 PROC/AGE CNFL
475 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.
217 PAYER CODE INVALID
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
107 RX EXCEEDS 12 MONTHS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
295 BASE RATE EXCEEDS LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
389 C&TC OUTREACH CAP EXCEEDED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENFIT PERIOD.
632 AUTH LIMIT REACHED - DD WAIVER
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENFIT PERIOD.
650 BENEFITS LIMITS EXHAUSTED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD
681 INPATIENT PER DAY LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
783 HBMHS LIMIT IS 48 HR PER 6 MO
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
784 MENT HLTH SESSION 5 DAY SPACE
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
785 INDIV PSYCH 10 DAY SPACING
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
786 DENTAL LIMIT OF 4/12 MOS.
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.
788 P.T. PROC EXCEEDS 1 HR/DAY
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
789 DENTAL PROC/OFF VISIT SAME DAY
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
791 IND HS ENCOUNTER LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
792 H.A. REPAIR SERV EXCEEDS LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
793 EVAL EXCEEDS 3 PER CAL. YR.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
795 UNITS EXCEED 23 PER CAL MO
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
796 DTH PILOT LIMIT EXCEEDED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
799 OUTPAT HOSPITAL LIM
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
001 PROPHY, FLUORIDE, 1/180 DAYS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
004 ONE SEALANT ALLOWED PER 5 YRS.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
008 DENTAL PROC WITHIN 5 YRS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
009 DENTAL PROCS WITHIN 1 YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
010 PERIAPICALS, 6 PER 12 MONTHS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
012
SERVICE EXCEEDS MONTHLY ALLOW
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
013 CW-TCM 1/MO
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
014 CHIRO VISITS EXCEED 6/MONTH
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
015 RELINE OR REBASE WITHIN 3 YRS.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
016 MED TRANS EXCEEDS 6/CAL MO
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
017 NUTRITIONAL CONSULT. 1/CAL. YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
018 NUTRIT CONSULT 2 FOLL-UP/CAL Y
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
019 EXCEEDS 6 UNITS PER CAL. YR.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
020 EXCEEDS 4 UNITS PER CAL. YR.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
021 EXCEEDS 36 UNITS PER CAL. YR.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
023 SERVICE ALLOWED ONCE IN 3 YRS
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.
024 SERVICE ALLOWED ONCE IN 4 YRS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
025 SERVICE ALLOWED ONCE/5 YRS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
026 EXCEEDS 16 UNITS PER CAL YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
032 AUD SPEECH OR H.A. SERV 1/CAL-NU
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
033 EXCEEDS 2 UNITS PER CAL. YR.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
034 O.T EVAL EXCEEDS 6/CAL. YR.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
035 O.T. CONSULT EXCEEDS 4/CAL. YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
036 O.T. SUPP EXCEEDS MAX/CAL YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
037 EXCEEDS 40 UNITS/CAL YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
038 SERVICE ALLOWED ONCE/CAL. YR.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
039 MAX UNITS PER DAY = 4
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
040 EXCEEDS 8 UNITS PER CAL YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
041 PT TEST OR AUD. LIMIT 2/CAL YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
042 P.T. ROM EXCEEDS 12/CAL YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
043 BREAST PUMP RR EXCEEDS ALLOW.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
044 SERVICE EXCEEDS YEARLY LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
045 EXCEEDS LIMIT OF 2 PER CAL YR.
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
046 H.A. CHECK EXCEEDS 4/CAL YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
047 MAX UNITS PER DAY = 2
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
048 1 YR PROC CODE EXCEEDS $ LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
049 POD SERV EXCEEDS ONCE/60 DAYS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
052 ACUPUNCTURE, LIMIT EXCEEDED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
053 DENTAL PROC LIMIT EXCEEDED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
054 LIMIT EXCEEDED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
055 HRG AID SERV EXCEEDS 1/CAL YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
057 MAX UNITS = 47
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
059 MAX UNITS PER DAY = 24
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
062 SERVICE ALLOWED ONCE IN 2 YRS
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.
063 1 UNIT ALLOWED/30 DAYS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
064 PRENATAL INIT EXCEEDS LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
065 MAX UNITS PER CAL MO = 1
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
066 MAX UNITS PER YEAR = 13
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
068 IEP THERAPY EVAL - 6 UNITS/DAY
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
069 IEP SERV EXCEEDS DAILY LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
071
DTH HOURLY SERV LIMIT EXCEEDED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
072 SPMI LIMIT - 1 PROVIDER/60 DAY
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
073 MULTIFAM GROUP PSYCH 20 HR/YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
074 GRP PSYCH 6 UNIT/WK 1 PRV ONLY
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
075 NEUROPSYCH CONSULT 20/78 YEAR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
076 HBMHS SKILLS TRAINING 192 HR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
077 EXPLAIN/FINDINGS 4 HOURS/YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
078 NEUROPSYCH TESTING 15 HR/YEAR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
079 PASARR DAILY OR CAL YR LIMIT
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
080 10 DAY SPACE BETWEEN SERVICES
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
081 INDIV/FAMILY PSYCH 5 DAY SPACE
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
082 PSYCH TESTNG LIMIT 32 UNITS/YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
083
DIFFERENT MH MODE 5 DAYS APART
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
084 MED MGMT LIMIT IS ONCE/7 DAYS
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
085 DAY TX LIMIT 3 UNIT/DAY 390 YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
086 TSFC BENEFITS EXHAUSTED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
087 FCSS BENEFITS EXHAUSTED
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
088 HBMHS TRAVEL TIME 128 HR/6 MO
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
089 COG RETRN 4 HR/DAY 390 HR/YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
090 SPMI OUT-OF-CTY TRAV 8 HR/DAY
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
091 5 DAY SPACING / DIFF MH PROV
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
092 SPMI EXCEEDS 10 HR/MO LIMIT
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.
093 SPMI TELEPHONE EXCEEDS 3 HR/MO
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
094 DIAG ASSESS 16 UNITS/CAL YEAR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
095 MED MGMT LIMIT IS 52 UNITS/YR
483 MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
097 MH-TCM LIMIT EXCEEDED
23
