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Routine: BARADJRI

BARADJRI.m

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  1. BARADJRI  ;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 BARADJRH
  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 5...")
  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.  ;;250;;Incorrect attachment/documentation received;;4;;300;;The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing.
  1.  ;;251;;Documentation recv'd was incomplete or deficient;;4;;301;;The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim.
  1.  ;;252;;Doc required to adjudicate clm/svc. At least one Remark Code must be provided.;;4;;302;;An attachment/other documentation is required to adjudicate this claim/service.
  1.  ;;253;;Sequestration - reduction in federal pymt.;;15;;303;;Sequestration - reduction in federal payment
  1.  ;;254;;Clm rcvd by dental plan but bnfts not avail. Submit to pt's medical plan;;4;;304;;Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.
  1.  ;;255;;Clm pending due to litigation.;;21;;305;;The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)
  1.  ;;256;;Svc not payable per managed care contract;;4;;306;;Service not payable per managed care contract.
  1.  ;;257;;Clm pending during the prem grace period, per Health Ins Exchange requirements;;21;;307;;The disposition of the claim is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim will be reversed and corrected when the grace period ends.
  1.  ;;258;;Clm/svc not cvrd when pt in cust/incarcerated. Fed,state,local auth may cover.;;4;;308;;Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.
  1.  ;;A0;;Patient refund amount;;19;;800;;Patient refund amount.
  1.  ;;A1;;Claim denied charges;;4;;801;;Claim/Service denied. 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.  ;;A2;;Contractual adjustment;;4;;802;;Contractual adjustment. Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
  1.  ;;A3;;Medicare Secondary Payer liability met;;4;;803;;Medicare Secondary Payer liability met.
  1.  ;;A4;;Medicare Claim PPS Capital Day Outlier Amount;;4;;804;;Medicare Claim PPS Capital Day Outlier Amount.
  1.  ;;A5;;Medicare Claim PPS Capital Cost Outlier Amount;;4;;805;;Medicare Claim PPS Capital Cost Outlier Amount.
  1.  ;;A6;;Prior hospitalization or 30 day transfer requirement not met;;4;;806;;Prior hospitalization or 30 day transfer requirement not met.
  1.  ;;A7;;Presumptive Payment Adjustment;;4;;807;;Presumptive Payment Adjustment
  1.  ;;A8;;Ungroupable DRG;;4;;808;;Ungroupable DRG.
  1.  ;;B1;;Non-covered visits;;4;;851;;Non-covered visits.
  1.  ;;B2;;Covered visits;;4;;852;;Covered visits.
  1.  ;;B3;;Covered charges;;4;;853;;Covered charges.
  1.  ;;B4;;Late filing penalty;;15;;854;;Late filing penalty.
  1.  ;;B5;;Coverage/program guidelines were not met or were exceeded;;4;;855;;Coverage/program guidelines were not met or were exceeded.
  1.  ;;B6;;Payment adj when performed/billed by type prv/type prv in type fac/prv specialty;;4;;856;;This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
  1.  ;;B7;;Provider not certified/eligible to be paid for proc/service on date of service;;4;;857;;This provider was not certified/eligible to be paid for this procedure/service on this date of service.
  1.  ;;B8;;Alternative services available and should have been utilized;;4;;858;;Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;B9;;Patient is enrolled in a Hospice;;4;;859;;Patient is enrolled in a Hospice.
  1.  ;;B10;;Allowed amount reduced. Component of basic proc was paid.;;4;;860;;Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
  1.  ;;B11;;Claim transferred to proper payer/processor. Service not covered by this payer.;;4;;861;;The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
  1.  ;;B12;;Services not documented in patients' medical records;;4;;862;;Services not documented in patients' medical records.
  1.  ;;B13;;Previously paid. Payment for claim/service provided in a previous payment;;4;;863;;Previously paid. Payment for this claim/service may have been provided in a previous payment.
  1.  ;;B14;;Payment denied. One visit or consultation per physician per day is covered.;;4;;864;;Only one visit or consultation per physician per day is covered.
  1.  ;;B15;;Service/procedure req that a qualifying service/proc be received and covered;;4;;865;;This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
  1.  ;;B16;;`New Patient' qualifications were not met;;4;;866;;`New Patient' qualifications were not met.
  1.  ;;B17;;Payment adjust-svc not prescribed by physician/prior to deliv, RX incomp/not curr;;4;;867;;Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.
  1.  ;;B18;;Procedure code and modifier invalid on date of service;;4;;868;;This procedure code and modifier was invalid on the date of service.
  1.  ;;B19;;Claim/service adjusted because of the finding of a Review Organization;;4;;869;;Claim/service adjusted because of the finding of a Review Organization.
  1.  ;;B20;;Procedure/service partially/fully furnished by another provider;;4;;870;;Procedure/service was partially or fully furnished by another provider.
  1.  ;;B21;;Charges reduced - service/care partially furnished by another physician;;4;;871;;The charges were reduced because the service/care was partially furnished by another physician.
  1.  ;;B22;;This payment is adjusted based on the diagnosis;;4;;872;;This payment is adjusted based on the diagnosis.
  1.  ;;B23;;Proc billed not authorized per CLIA proficiency test;;4;;873;;Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
  1.  ;;D1;;Claim/service denied. Level of subluxation is missing or inadequate;;4;;901;;Claim/service denied. Level of subluxation is missing or inadequate. Notes: Use code 16 and remark codes if necessary.
  1.  ;;D2;;Claim lacks the name, strength, or dosage of the drug furnished;;4;;902;;Claim lacks the name, strength, or dosage of the drug furnished. Notes: Use code 16 and remark codes if necessary.
  1.  ;;D3;;Claim/service denied - info indicating pat own equip requiring part/supply missing;;4;;903;;Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
  1.  ;;D4;;Claim/service does not indicate the period of time for which this will be needed;;4;;904;;Claim/service does not indicate the period of time for which this will be needed. Notes: Use code 16 and remark codes if necessary.
  1.  ;;D5;;Claim/service denied - claim lacks individual lab codes included in the test;;4;;905;;Claim/service denied. Claim lacks individual lab codes included in the test. Notes: Use code 16 and remark codes if necessary.
  1.  ;;D6;;Claim/service denied - claim not include patient's medical record for the service;;4;;906;;Claim/service denied. Claim did not include patient's medical record for the service. Notes: Use code 16 and remark codes if necessary.
  1.  ;;D7;;Claim/service denied - claim lacks date of patient's most recent physician visit;;4;;907;;Claim/service denied. Claim lacks date of patient's most recent physician visit. Notes: Use code 16 and remark codes if necessary.
  1.  ;;D8;;Claim/service denied - claim lacks indicator that `x-ray is available for review;;4;;908;;Claim/service denied. Claim lacks indicator that `x-ray is available for review'. Notes: Use code 16 and remark codes if necessary.
  1.  ;;D9;;Claim/svc denied - need inv/stat cert act cost lens-disc/type intraocular lens;;4;;909;;Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
  1.  ;;D10;;Claim/svc denied - Completed phys financial relationship form not on file;;4;;910;;Claim/service denied. Completed physician financial relationship form not on file. Notes: Use code 17.
  1.  ;;D11;;Claim lacks completed pacemaker registration form;;4;;911;;Claim lacks completed pacemaker registration form. Notes: Use code 17.
  1.  ;;D12;;Claim/svc denied - need ident who performed the purchased diag test/amt charged;;4;;912;;Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Notes: Use code 17.
  1.  ;;D13;;Claim/svc denied - performed by fac/supplier where order/refer phys has finan int;;4;;913;;Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Notes: Use code 17.
  1.  ;;D14;;Claim lacks indication that plan of treatment is on file;;4;;914;;Claim lacks indication that plan of treatment is on file. Notes: Use code 17.
  1.  ;;D15;;Claim lacks indication that service was supervised or evaluated by a physician;;4;;915;;Claim lacks indication that service was supervised or evaluated by a physician. Notes: Use code 17.
  1.  ;;D16;;Claim lacks prior payment information;;4;;900;;Claim lacks prior payer payment information. Notes: Use code 16 with appropriate claim payment remark code [N4].
  1.  ;;D17;;Claim/service has invalid non-covered days;;4;;927;;Claim/Service has invalid non-covered days. Notes: Use code 16 with appropriate claim payment remark code.
  1.  ;;D18;;Claim/service has missing diagnosis information;;4;;928;;Claim/Service has missing diagnosis information. Notes: Use code 16 with appropriate claim payment remark code.
  1.  ;;D19;;Claim/service lacks physician/operative or other supporting documentation;;4;;929;;Claim/Service lacks Physician/Operative or other supporting documentation. Notes: Use code 16 with appropriate claim payment remark code.
  1.  ;;D20;;Claim/service missing service/product information;;4;;970;;Claim/Service missing service/product information. Notes: Use code 16 with appropriate claim payment remark code.
  1.  ;;D21;;This (these) diagnosis(es) is/are missing or are invalid;;4;;971;;This (these) diagnosis(es) is (are) missing or are invalid.
  1.  ;;D22;;Reimbursement adjust-reasons to be provided in separate correspondence (WC only);;4;;972;;Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only).
  1.  ;;D23;;Dual elig pt covered by Medicare Part D per Medicare Retro-Eligibility;;4;;973;;This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility.
  1.  ;;END
  1.  ;;