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Routine: BARADJR4

BARADJR4.m

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  1. BARADJR4 ; IHS/SD/LSL - CREATE ENTRY IN A/R EDI STND CLAIM ADJ REASON ;
  1.  ;;1.8;IHS ACCOUNTS RECEIVABLE**20**;;OCT 26, 2005
  1.  ; IHS/SD/SDR - v1.8 p20 - updated SARs
  1.  ;
  1.  ; *********************************************************************
  1. STND2 ;
  1.  S BARCNT=BARCNT+1
  1.  S BARVALUE=$P($T(@2+BARCNT),BARD,2,6)
  1.  Q:BARVALUE="END"
  1.  D STND3^BARADJR3
  1.  Q
  1. 2 ;; A/R EDI STND Claim Adj Reasons file - Adds
  1.  ;;31;;Patient cannot be identified as insured;;4;;166;;Patient cannot be identified as our insured.
  1.  ;;32;;Our records indicate that dependent is not eligible dependent as defined;;4;;632;;Our records indicate that this dependent is not an eligible dependent as defined.
  1.  ;;33;;Insured has no dependent coverage;;4;;633;;Insured has no dependent coverage.
  1.  ;;34;;Insured has no coverage for newborns;;4;;17;;Insured has no coverage for newborns.
  1.  ;;35;;Lifetime benefit maximum has been reached;;4;;167;;Lifetime benefit maximum has been reached.
  1.  ;;36;;Balance does not exceed co-payment amount;;4;;636;;Balance does not exceed co-payment amount.
  1.  ;;37;;Balance does not exceed deductible;;4;;637;;Balance does not exceed deductible.
  1.  ;;38;;Services not provided or authorized by designated (network) providers;;4;;638;;Services not provided or authorized by designated (network/primary care) providers.
  1.  ;;39;;Services denied at the time authorization/pre-certification was requested;;4;;639;;Services denied at the time authorization/pre-certification was requested.
  1.  ;;40;;Charges do not meet qualifications for emergent/urgent care;;4;;640;;Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;41;;Discount agreed to in Preferred Provider contract;;4;;168;;Discount agreed to in Preferred Provider contract.
  1.  ;;42;;Charges exceed our fee schedule or maximum allowable amount;;4;;21;;"Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)".
  1.  ;;43;;Gramm-Rudman reduction;;4;;643;;Gramm-Rudman reduction.
  1.  ;;44;;Prompt-pay discount;;4;;644;;Prompt-pay discount.
  1.  ;;45;;Charges exceed fee schedule/max allow or contracted/legislated fee arrangement;;4;;645;;Charges exceed fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
  1.  ;;46;;This (these) service(s) is (are) not covered;;4;;122;;This (these) service(s) is (are) not covered. Notes: Use code 96.
  1.  ;;47;;This (these) diagnosis(es) is (are) not covered, missing, or are invalid;;4;;647;;This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
  1.  ;;48;;This (these) procedure(s) is (are) not covered;;4;;648;;This (these) procedure(s) is (are) not covered. Notes: Use code 96.
  1.  ;;49;;Non-covered services-routine exam/screening proc in conj w/routine exam;;4;;20;;These are non-covered srvcs because this is rtn exam or screening procedure done in conj. with rtn exam. Note: Refer to 835 Healthcare Policy Iden. Segment (loop 2110 Srvc Pymt Info REF), if present.
  1.  ;;50;;Non-covered services-not deemed a `medical necessity' by the payer;;4;;169;;These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to 835 Healthcare Policy Identification Segment (loop 2110 Srvc Pymt Info REF), if present.
  1.  ;;51;;Non-covered services-pre-existing condition;;4;;19;;These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;52;;Ref/prescrib/render/Prv not eligible to ref/prescrib/order/perform svc billed;;4;;178;;The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
  1.  ;;53;;Services by an immediate relative/member of the same household are not covered;;4;;653;;Services by an immediate relative or a member of the same household are not covered.
  1.  ;;54;;Multiple physicians/assistants are not covered in this case;;4;;654;;Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;55;;Claim/svc denied-proc/trtmnt deemed experimental/investigational by the payer;;4;;655;;Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;56;;Claim/svc denied-proc/trtmnt not deemed `proven to be effective' by the payer;;4;;656;;Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;57;;Payment denied/reduced-doc not support level/#/length of svc/dosage/day's supply;;4;;657;;Pymt denied/reduced because payer deems info submitted does not support this lvl of srvc/many srvcs/lgth of srvc, this dosage, or this day's supply. Note: Split into codes 150,151,152,153,and 154.
  1.  ;;58;;Payment adjusted-trtmnt rendered in inappropriate/invalid place of svc;;4;;658;;Treatment was deemed by payer to have been rendered in inappropriate/invalid place of service. Note: Refer to 835 Healthcare Policy Identification Segment (loop 2110 Srvc Pymt Info REF), if present.
  1.  ;;59;;Charges adjusted- multiple surgery rules/concurrent anesthesia rules;;4;;659;;Processed based on multi/concurrent proc rules. (e.g., multi-surgery or diag. imaging, concurrent anes.) Note: Refer to 835 Healthcare Policy ID Segment (loop 2110 Srvc Pymt Info REF), if present.
  1.  ;;60;;Charges for outpat svcs w/this proximity to inpat svcs not covered;;4;;660;;Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
  1.  ;;61;;Charges adjusted-penalty for failure to obtain second surgical opinion;;21;;661;;Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;62;;Payment denied/reduced-absence of/exceeded, pre-certification/authorization;;15;;662;;Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
  1.  ;;63;;Correction to a prior claim;;4;;663;;Correction to a prior claim.
  1.  ;;64;;Denial reversed per Medical Review;;22;;664;;Denial reversed per Medical Review.
  1.  ;;65;;Procedure code was incorrect. This payment reflects the correct code;;4;;665;;Procedure code was incorrect. This payment reflects the correct code.
  1.  ;;66;;Blood Deductible;;13;;666;;Blood Deductible.
  1.  ;;67;;Lifetime reserve days;;4;;667;;Lifetime reserve days. (Handled in QTY, QTY01=LA).
  1.  ;;68;;DRG weight;;16;;93;;DRG weight. (Handled in CLP12).
  1.  ;;69;;Day outlier amount;;4;;669;;Day outlier amount.
  1.  ;;70;;Cost outlier - Adjustment to compensate for additonal costs;;4;;670;;Cost outlier - Adjustment to compensate for additonal costs.
  1.  ;;71;;Primary Payer amount;;4;;165;;Primary Payer amount. Notes: Use code 23.
  1.  ;;72;;Coinsurance day;;14;;672;;Coinsurance day. (Handled in QTY, QTY01=CD).
  1.  ;;73;;Administrative days;;4;;673;;Administrative days.
  1.  ;;74;;Indirect Medical Education Adjustment;;4;;674;;Indirect Medical Education Adjustment.
  1.  ;;75;;Direct Medical Education Adjustment;;4;;675;;Direct Medical Education Adjustment.
  1.  ;;76;;Disproportionate Share Adjustment;;4;;676;;Disproportionate Share Adjustment.
  1.  ;;77;;Covered days;;4;;677;;Covered days. (Handled in QTY, QTY01=CA).
  1.  ;;78;;Non-Covered days/Room charge adjustment;;4;;678;;Non-Covered days/Room charge adjustment.
  1.  ;;79;;Cost Report days;;4;;679;;Cost Report days. (Handled in MIA15).
  1.  ;;80;;Outlier days;;4;;680;;Outlier days. (Handled in QTY, QTY01=OU).
  1.  ;;81;;Discharges;;4;;681;;Discharges.
  1.  ;;82;;PIP days;;4;;682;;PIP days.
  1.  ;;83;;Total visits;;4;;683;;Total visits.
  1.  ;;84;;Capital Adjustment;;4;;684;;Capital Adjustment. (Handled in MIA).
  1.  ;;85;;Patient interest amount;;4;;685;;Patient Interest Adjustment (Use Only Group code PR). Notes: Only use when the payment of interest is the responsibility of the patient.
  1.  ;;86;;Statutory Adjustment;;4;;686;;Statutory Adjustment. Notes: Duplicative of code 45.
  1.  ;;87;;Transfer amount;;4;;687;;Transfer amount.
  1.  ;;88;;Adj amt represents collection against receivable created in prior overpayment;;21;;688;;Adjustment amount represents collection against receivable created in prior overpayment.
  1.  ;;89;;Professional fees removed from charges;;4;;689;;Professional fees removed from charges.
  1.  ;;90;;Ingredient cost adjustment;;4;;690;;Ingredient cost adjustment. Note: To be used for pharmaceuticals only.
  1.  ;;91;;Dispensing fee adjustment;;3;;691;;Dispensing fee adjustment.
  1.  ;;92;;Claim Paid in full;;22;;692;;Claim Paid in full.
  1.  ;;93;;No Claim level Adjustments;;22;;693;;No Claim level Adjustments. Notes: As of 004010, CAS at the claim level is optional.
  1.  ;;94;;Processed in Excess of charges;;16;;694;;Processed in Excess of charges.
  1.  ;;95;;Plan procedures not followed;;4;;695;;Plan procedures not followed.
  1.  ;;96;;Non-covered charge(s);;4;;696;;Non-cov'd chg(s). At least 1 Rmk Cd must be provided (may be NCPDP Rej Rsn Cd, or Remit Advc Rmrk Cd, not ALERT.) Note: Refer to 835 Hlthcre Policy ID Sgmt (loop 2110 Srvc Pymt Info REF), if present.
  1.  ;;97;;Benefit included in the pymt/allow for another service/procedure already adjud;;4;;697;;The benft for this srvc is incl. in pymt/allowance for another srvc/procedure that has already been adjudicated. Note: Refer to 835 Hlthcre Policy ID Sgmt (loop 2110 Srvc Pymt Info REF), if present.
  1.  ;;98;;Hospital must file Medicare claim for this inpatient non-physician service;;21;;698;;The hospital must file the Medicare claim for this inpatient non-physician service.
  1.  ;;99;;Medicare Secondary Payer Adjustment Amount;;4;;699;;Medicare Secondary Payer Adjustment Amount.
  1.  ;;100;;Payment made to patient/insured/responsible party/employer;;4;;23;;Payment made to patient/insured/responsible party/employer.
  1.  ;;101;;Predetermination: anticipate payment upon completion of svcs/claim adjudication;;21;;701;;Predetermination: anticipated payment upon completion of services or claim adjudication.
  1.  ;;102;;Major Medical Adjustment;;4;;702;;Major Medical Adjustment.
  1.  ;;103;;Provider promotional discount (e.g., Senior citizen discount);;4;;703;;Provider promotional discount (e.g., Senior citizen discount).
  1.  ;;104;;Managed care withholding;;4;;704;;Managed care withholding.
  1.  ;;105;;Tax withholding;;4;;705;;Tax withholding.
  1.  ;;106;;Patient payment option/election not in effect;;4;;706;;Patient payment option/election not in effect.
  1.  ;;107;;Related or qualifying claim/service not identified on claim;;4;;707;;The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;108;;Rent/purchase guidelines were not met;;4;;708;;Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;109;;Claim not covered by payer/contractor. Send claim to correct payer/contractor;;4;;709;;Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
  1.  ;;110;;Billing date predates service date;;4;;710;;Billing date predates service date.
  1.  ;;111;;Not covered unless the provider accepts assignment;;4;;711;;Not covered unless the provider accepts assignment.
  1.  ;;112;;Payment adjusted as not furnished directly to the patient and/or not documented;;4;;180;;Service not furnished directly to the patient and/or not documented.
  1.  ;;113;;Payment denied-service/procedure provided outside the US or as a result of war;;4;;713;;Payment denied because service/procedure was provided outside the United States or as a result of war. Notes: Use Codes 157, 158, or 159.
  1.  ;;114;;Procedure/product not approved by the Food and Drug Administration;;4;;714;;Procedure/product not approved by the Food and Drug Administration.
  1.  ;;115;;Procedure postponed or canceled;;4;;715;;Procedure postponed, canceled, or delayed.
  1.  ;;116;;Advance indemnification notice signed by patient did not comply w/requirements;;4;;716;;The advance indemnification notice signed by the patient did not comply with requirements.
  1.  ;;117;;Transport only covered closest facility that can provide necessary care;;4;;717;;Transportation is only covered to the closest facility that can provide the necessary care.
  1.  ;;118;;ESRD network support adjustment;;4;;718;;ESRD network support adjustment.
  1.  ;;119;;Benefit maximum for this time period or occurrence has been reached;;4;;719;;Benefit maximum for this time period or occurrence has been reached.
  1.  ;;120;;Patient is covered by a managed care plan;;4;;720;;Patient is covered by a managed care plan. Notes: Use code 24.
  1.  ;;121;;Indemnification adjustment;;4;;721;;Indemnification adjustment - compensation for outstanding member responsibility.
  1.  ;;122;;Psychiatric reduction;;4;;722;;Psychiatric reduction.
  1.  ;;123;;Payer refund due to overpayment;;22;;723;;Payer refund due to overpayment.
  1.  ;;124;;Payer refund amount - not our patient;;22;;724;;Payer refund amount - not our patient. Notes: Refer to implementation guide for proper handling of reversals.
  1.  ;;125;;Submission/billing error(s);;4;;725;;Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
  1.  ;;126;;Deductible -- Major Medical;;13;;726;;Deductible -- Major Medical. Notes: Use Group Code PR and code 1.
  1.  ;;127;;Coinsurance -- Major Medical;;14;;727;;Coinsurance -- Major Medical. Notes: Use Group Code PR and code 2.
  1.  ;;128;;Newborn's services are covered in the mother's Allowance;;4;;728;;Newborn's services are covered in the mother's Allowance.
  1.  ;;129;;Prior processing information appears incorrect;;4;;164;;Prior processing information appears incorrect.
  1.  ;;130;;Claim submission fee;;4;;730;;Claim submission fee.
  1.  ;;131;;Claim specific negotiated discount;;4;;731;;Claim specific negotiated discount.
  1.  ;;132;;Prearranged demonstration project adjustment;;4;;732;;Prearranged demonstration project adjustment.
  1.  ;;133;;The disposition of this claim/service is pending further review;;21;;733;;The disposition of this claim/service is pending further review.
  1.  ;;134;;Technical fees removed from charges;;4;;734;;Technical fees removed from charges.
  1.  ;;135;;Interim bills cannot be processed;;4;;735;;Interim bills cannot be processed.
  1.  ;;END