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Routine: BARADJRG

BARADJRG.m

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  1. BARADJRG  ;IHS/SD/POT - CREATE ENTRY IN A/R EDI STND CLAIM ADJ REASON ;
  1.  ;;1.8;IHS ACCOUNTS RECEIVABLE;**28**;OCT 26, 2005;Build 92
  1.  ; IHS/DIT/CPC HEAT326081 - V1.8 P28 - updated SARs
  1.  ; Continuation of BARADJRF
  1.  ; *********************************************************************
  1. EN ; EP
  1.  ; Update A/R EDI Stnd Adj Reason Descriptions
  1.  S BARD=";;"
  1.  S BARCNT=0
  1.  D BMES^XPDUTL("A/R EDI STND CLAIM ADJ REASONS Phase 3...")
  1.  F  D UPDSTND2 Q:BARVALUE="END"
  1.  K DIC,DA,X,Y,DIE
  1.  D ^BARVKL0
  1.  Q
  1.  ; ********************************************************************
  1. UPDSTND2 ;
  1.  S BARCNT=BARCNT+1
  1.  S BARVALUE=$P($T(@1+BARCNT),BARD,2,6)
  1.  Q:BARVALUE="END"
  1.  K DIC,DA,X,Y,DIE
  1.  S DA=0
  1.  S DA=$O(^BARADJ("B",$P(BARVALUE,BARD),DA))
  1.  Q:+DA<=0
  1.  S DIE="^BARADJ("
  1.  S DR=".02///^S X=$E($P(BARVALUE,BARD,2),1,80);101///^S X=$E($P(BARVALUE,BARD,5),1,200)"
  1.  D ^DIE
  1.  D MES^XPDUTL($P(BARVALUE,BARD)_$S($L($P(BARVALUE,BARD))=2:"   ",$L($P(BARVALUE,BARD))=1:"    ",1:"  ")_$E($P(BARVALUE,BARD,2),1,65))
  1.  Q
  1.  ; ********************************************************************
  1.  ; STND CODE ;; SHORT DESC ;; RPMS CAT ;; RPMS TYP ;; LONG DESC
  1.  ; ********************************************************************
  1. 1 ;;DIC="^BARADJ("
  1.  ;;95;;Plan procedures not followed;;4;;695;;Plan procedures not followed.
  1.  ;;96;;Non-covered charge(s);;4;;696;;Non-covered charge(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.  ;;97;;Benefit included in payment for another service already adjudicated;;4;;697;;The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
  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. Effective 05/01/2018: Payment made to patient/insured/responsible party.
  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. Usage: 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. Usage: 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/service not covered by this payer/contractor. You must send the claim/service 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 signed by the 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. At least one Remark Code must be provided. )
  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 service line is pending further review;;21;;733;;The disposition of this service line is pending further review. (Use only with Group Code OA).
  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.  ;;136;;Failure to follow prior payer's coverage rules;;4;;736;;Failure to follow prior payer's coverage rules. (Use only with Group Code OA).
  1.  ;;137;;Regulatory Surcharges/Assessments/Allowances/Health Related Taxes;;4;;141;;Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
  1.  ;;138;;Appeal procedures not followed or time limits not met;;4;;738;;Appeal procedures not followed or time limits not met.
  1.  ;;139;;Contracted funding agreement - Subscriber employed by the provider of services;;4;;739;;Effective 05/01/2018: Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.
  1.  ;;140;;Patient/Insured health identification number and name do not match;;4;;740;;Patient/Insured health identification number and name do not match.
  1.  ;;141;;Claim spans eligible and ineligible periods of coverage;;4;;125;;Claim spans eligible and ineligible periods of coverage.
  1.  ;;142;;Monthly Medicaid patient liability amount;;4;;742;;Monthly Medicaid patient liability amount.
  1.  ;;143;;Portion of payment deferred;;21;;743;;Portion of payment deferred.
  1.  ;;144;;Incentive adjustment, e.g. preferred product/service;;4;;744;;Incentive adjustment, e.g. preferred product/service.
  1.  ;;145;;Premium payment withholding;;4;;745;;Premium payment withholding Notes: Use Group Code CO and code 45
  1.  ;;146;;Diagnosis invalid for the date(s) of service reported;;4;;746;;Diagnosis was invalid for the date(s) of service reported.
  1.  ;;147;;Provider contracted/negotiated rate expired or not on file;;4;;747;;Provider contracted/negotiated rate expired or not on file.
  1.  ;;148;;Information from another provider was not provided or was insuff/incomplete;;4;;748;;Information from another provider was not provided or was insufficient/incomplete.
  1.  ;;149;;Lifetime benefit maximum has been reached for this service/benefit category;;4;;749;;Lifetime benefit maximum has been reached for this service/benefit category.
  1.  ;;150;;Payer deems the info submitted does not support level of service;;4;;754;;Payer deems the information submitted does not support this level of service.
  1.  ;;151;;Pmt adjusted - payer deems the info submitted not support this many svcs;;4;;750;;Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
  1.  ;;152;;Payer deems the info submitted not support this lgth of svc;;4;;751;;Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;153;;Payer deems the info submitted does not support this dosage;;4;;752;;Payer deems the information submitted does not support this dosage.
  1.  ;;154;;Payer deems the info submitted does not support this day's supply;;4;;753;;Payer deems the information submitted does not support this day's supply.
  1.  ;;155;;Patient refused the service/procedure;;4;;755;;Patient refused the service/procedure.
  1.  ;;156;;Flexible spending account payments.;;22;;756;;Flexible spending account payments. Note: Use code 187.
  1.  ;;157;;Service/procedure provided as a result of an act of war;;4;;757;;Service/procedure was provided as a result of an act of war.
  1.  ;;158;;Service/procedure provided outside the United States;;4;;758;;Service/procedure was provided outside of the United States.
  1.  ;;159;;Service/procedure provided as a result of terrorism;;4;;759;;Service/procedure was provided as a result of terrorism.
  1.  ;;160;;Injury/illness result of activity that's a benefit exclusion;;4;;760;;Injury/illness was the result of an activity that is a benefit exclusion.
  1.  ;;161;;Provider performance bonus;;16;;922;;Provider performance bonus.
  1.  ;;162;;State-mandated requirment for property/casulty--see claim payment remark codes;;4;;762;;State-mandated Requirement for Property and Casualty, see Claim Payment Remarks code for specific explanation.
  1.  ;;163;;Attachment referenced on the claim was not received;;21;;763;;Attachment/other documentation referenced on the claim was not received.
  1.  ;;164;;Attachment referenced on the claim was not received in a timely fashion;;4;;764;;Attachment/other documentation referenced on the claim was not received in a timely fashion.
  1.  ;;165;;Referral absent or exceeded;;15;;765;;Referral absent or exceeded.
  1.  ;;166;;Service submitted to payer after responsibility for processing claims ended;;4;;766;;These services were submitted after this payers responsibility for processing claims under this plan ended.
  1.  ;;167;;This (these) diagnosis(es) is (are) not covered;;4;;767;;This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;168;;Svcs have been considerd under pts med plan. Benfts not avail under dental plan;;4;;768;;Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
  1.  ;;169;;Alternate benefit has been provided;;4;;769;;Alternate benefit has been provided.
  1.  ;;170;;Payment denied when performed/billed by this type of provider;;4;;770;;Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;171;;Payment denied when performed by this type of provider in this type of facility;;4;;771;;Payment is denied when performed/billed by this type of provider in this type of facility.
  1.  ;;172;;Payment adjusted when perfomed/billed by a provider of this specialty;;4;;772;;Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;173;;Service/equipment was not prescribed by a physician;;4;;773;;Service/equipment was not prescribed by a physician.
  1.  ;;174;;Service was not prescribed prior to delivery;;4;;774;;Service was not prescribed prior to delivery.
  1.  ;;175;;Prescription is incomplete;;4;;775;;Prescription is incomplete.
  1.  ;;176;;Prescription is not current;;4;;776;;Prescription is not current.
  1.  ;;177;;Patient has not met the required eligibility requirements;;4;;777;;Patient has not met the required eligibility requirements.
  1.  ;;178;;Patient has not met the required spend down requirements;;4;;778;;Patient has not met the required spend down requirements.
  1.  ;;179;;Patient has not met the required waiting requirements;;4;;779;;Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;END
  1.  ;;