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Routine: BARADJRK

BARADJRK.m

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  1. BARADJRK  ;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/SD/CPC HEAT326081 - V1.8 P28 - updated SARs
  1.  ; code cloned from BARADJR7
  1.  ;
  1. EN ; EP
  1.  ; Change Name of these reasons
  1.  S BARD=";;"
  1.  S BARCNT=0
  1.  D BMES^XPDUTL("Updating Adjustment Reasons to A/R Table Entry file Phase 1...")
  1.  F  D CHNGREA2 Q:BARVALUE="END"
  1.  K DIC,DA,X,Y,DIE
  1.  D ^BARVKL0
  1.  Q
  1.  ; ********************************************************************
  1. CHNGREA2 ;
  1.  S BARCNT=BARCNT+1
  1.  S BARVALUE=$P($T(@4+BARCNT),BARD,2)
  1.  Q:BARVALUE="END"
  1.  K DIC,DA,X,Y,DIE
  1.  S DIC="^BARTBL("
  1.  S DIC(0)="M"
  1.  S X=BARVALUE
  1.  D ^DIC
  1.  I +Y>0 D
  1.  .K DIC,DIE,BARNAME
  1.  .S DIE="^BARTBL("
  1.  .S DA=+Y
  1.  .S BARNAME=$P($T(@4+BARCNT),BARD,3)
  1.  .S DR=".01////^S X=BARNAME"
  1.  .D ^DIE
  1.  .D MES^XPDUTL(BARVALUE_$S($L(BARVALUE)=2:"   ",$L(BARVALUE)=1:"    ",1:"  ")_BARNAME)
  1.  Q
  1.  ; ********************************************************************
  1.  ; STANDARD CODE ;; RPMS REASON
  1.  ; ********************************************************************
  1. 4 ;;A/R Table Entry file - Edits DIE="^BARTBL("
  1.  ;;15;;Wrkrs comp State Fee Sched Adj;;3;;W1
  1.  ;;17;;Clm Den Insured no Cov for NB;;4;;34
  1.  ;;19;;Non Cov Srv PreExist Condition;;4;;51
  1.  ;;20;;Non Cov Srv Routine Exam;;4;;49
  1.  ;;21;;Chrgs Excd Max Allowable Amt;;4;;42
  1.  ;;23;;Pymt Made to PT/Insrd/Res Prty;;4;;100
  1.  ;;27;;Co-payment;;14;;3
  1.  ;;29;;Deductible;;13;;1
  1.  ;;93;;DRG Weight;;16;;68
  1.  ;;122;;Services Not Covered;;4;;46
  1.  ;;125;;Clm Adj Spans Elig/Inelig Date;;4;;141
  1.  ;;134;;Time Limit for Filing Expired;;4;;29
  1.  ;;135;;Duplicate Claim/Service;;3;;18
  1.  ;;141;;Regulatory surcharge/allowance;;4;;137
  1.  ;;164;;Pymt Den Prior Info Incorrect;;4;;129
  1.  ;;165;;Primary Payer Amount;;4;;71
  1.  ;;166;;Pt cannot be ID'd as insured;;4;;31
  1.  ;;167;;Lifetime max benefit reached;;4;;35
  1.  ;;168;;Disc Agrmt Pref Prov Contract;;4;;41
  1.  ;;169;;Non Cov Srv Not Medically Nec;;4;;50
  1.  ;;178;;Prov Not Elig to Provd Serv/Bl;;4;;52
  1.  ;;180;;Svc not furnished direct to pt;;4;;112
  1.  ;;300;;Incorrect attchmt/documnt rcvd;;4;;250
  1.  ;;301;;Incomplete or deficient docs;;4;;251
  1.  ;;302;;Doc reqd to adjudicate clm/svc;;4;;252
  1.  ;;303;;Sequestration-red in fed pymt;;15;;253
  1.  ;;304;;No bnfts-Submit svcs to med pl;;4;;254
  1.  ;;305;;Clm pending due to litigation;;21;;255
  1.  ;;306;;Not payable per mngd care cont;;4;;256
  1.  ;;307;;Clm pndng during prem grace pd;;21;;257
  1.  ;;308;;Clm not cvrd - pt incarcerated;;4;;258
  1.  ;;401;;ST-mandated rqrmt for property;;22;;P1
  1.  ;;402;;No WC liab-Not wrk rel inj/ill;;4;;P2
  1.  ;;403;;WC case settled, pt resp;;4;;P3
  1.  ;;404;;WC case adjudicated as non-WC;;4;;P4
  1.  ;;405;;Based on payer reas & cust fee;;4;;P5
  1.  ;;406;;Based on entitlement to bnfts;;4;;P6
  1.  ;;407;;Resub w/correct proc code;;22;;P7
  1.  ;;408;;Claim is under investigation.;;22;;P8
  1.  ;;409;;No CPT/HCPCS to describe svc;;4;;P9
  1.  ;;410;;Pmt reduc to zero, litigation;;4;;P10
  1.  ;;411;;Clm pending due to litigation;;21;;P11
  1.  ;;412;;WC fee schedule adjustment;;4;;P12
  1.  ;;413;;Pmt red/den due to WC policies;;4;;P13
  1.  ;;414;;Pmt incl w/pmt for other svc;;4;;P14
  1.  ;;415;;WC Med Trtmt Guideline adjstmt;;4;;P15
  1.  ;;416;;Med prov not auth'd for WC;;4;;P16
  1.  ;;417;;Referral not auth'd by attndng;;15;;P17
  1.  ;;418;;Proc not listed/comp svc allwd;;4;;P18
  1.  ;;419;;No pymt due,proc fee is zero;;4;;P19
  1.  ;;420;;Svc not pd under oupt fee schd;;4;;P20
  1.  ;;421;;TPL Payment denied-MPC/PIP;;4;;P21
  1.  ;;422;;TPL Payment adjusted-MPC/PIP;;4;;P22
  1.  ;;423;;TPL Fee Sch Adjust-MPC/PIP;;4;;P23
  1.  ;;602;;Coinsurance Amount;;14;;2
  1.  ;;604;;Proc code inconst w/mod;;4;;4
  1.  ;;605;;Proc Code/TOB inconst w/POS;;4;;5
  1.  ;;606;;Proc/Rev Code inconst w/pt age;;4;;6
  1.  ;;607;;Proc Code inconst w/pt gender;;4;;7
  1.  ;;608;;Proc Code inconst w/Prov Type;;4;;8
  1.  ;;609;;DX inconst w/pt age;;4;;9
  1.  ;;610;;DX inconst w/pt gender;;4;;10
  1.  ;;611;;DX inconst w/proc;;4;;11
  1.  ;;612;;DX inconst w/Prov Type;;4;;12
  1.  ;;613;;Date of death precedes DOS;;4;;13
  1.  ;;614;;Date of birth follows DOS;;4;;14
  1.  ;;615;;Auth Number missing/invalid;;4;;15
  1.  ;;616;;Clm/Srvc Lacks Info For Adjud;;4;;16
  1.  ;;617;;Pymt Adj Info Incomplete;;4;;17
  1.  ;;619;;Clm Denied work related injury;;4;;19
  1.  ;;620;;Clm Den Injry Covrd Liab Carr;;4;;20
  1.  ;;621;;Inj liability of no-fault ins;;4;;21
  1.  ;;622;;Covd by another payer per COB;;4;;22
  1.  ;;623;;Chrgs pd/adj by another payer;;4;;23
  1.  ;;624;;Chrgs covd by cap agreement;;4;;24
  1.  ;;625;;Pymt Den Stoploss Ded Not Met;;4;;25
  1.  ;;626;;Expnse Incrrd Prior to Coverag;;4;;26
  1.  ;;627;;Expnse Incrrd Aft Cov Termnatd;;4;;27
  1.  ;;628;;Coverage Not in Effect on DOS;;4;;28
  1.  ;;630;;Requirements for elig not met;;4;;30
  1.  ;;632;;Records Indicate Dep Not Elig;;4;;32
  1.  ;;633;;Clm DenInsured No Depend Cove;;4;;33
  1.  ;;636;;Bal Does not Exceed CoPymt Amt;;4;;36
  1.  ;;637;;Bal Does not Exceed Deductible;;4;;37
  1.  ;;638;;Serv Not Auth by Designtd Prov;;4;;38
  1.  ;;639;;Service denied at prior auth;;4;;39
  1.  ;;640;;Criteria for ER/UC not met;;4;;40
  1.  ;;643;;Gramm-Rudman reduction;;4;;43
  1.  ;;644;;Prompt Pay Discount;;4;;44
  1.  ;;645;;Chgs exceed fee schd/max allow;;4;;45
  1.  ;;647;;Dx not Covered/Missing/Invalid;;4;;47
  1.  ;;648;;Procedure Not Covered;;4;;48
  1.  ;;653;;Srv by immed relative not cov;;4;;53
  1.  ;;654;;Mult Prov Not Cov in This Case;;4;;54
  1.  ;;655;;Clm Srv deemed experimental;;4;;55
  1.  ;;656;;Proc not deemed as effective;;4;;56
  1.  ;;657;;Pymt Den Info Submtd Not Suff;;4;;57
  1.  ;;658;;Invalid/inappropriate POS;;4;;58
  1.  ;;659;;Mult surgery/concurrent rules;;4;;59
  1.  ;;660;;Outpt srv w/in inpt proximity;;4;;60
  1.  ;;661;;Failed to obtain sec surg opin;;21;;61
  1.  ;;662;;Pymt Den/Reducd No Precrt Auth;;15;;62
  1.  ;;663;;Correction to Prior Claim;;4;;63
  1.  ;;664;;Denial reversed per Med Review;;22;;64
  1.  ;;665;;Pmt Den/Reducd Proc Code Wrong;;4;;65
  1.  ;;666;;Blood Deductible;;13;;66
  1.  ;;667;;Lifetime Reserve Days;;4;;67
  1.  ;;669;;Day Outlier Amount;;4;;69
  1.  ;;670;;Cost Outlr Adj for Addl Cost;;4;;70
  1.  ;;672;;Coinsurance Day;;14;;72
  1.  ;;673;;Administrative Days;;4;;73
  1.  ;;674;;Indirect Med Educ Adjustment;;4;;74
  1.  ;;675;;Direct Med Educ Adjustment;;4;;75
  1.  ;;676;;Disproportionate Share Adj;;4;;76
  1.  ;;677;;Covered Days;;4;;77
  1.  ;;678;;Non Covered Days/Room Chrg Adj;;4;;78
  1.  ;;679;;Cost Report Days;;4;;79
  1.  ;;680;;Outlier Days;;4;;80
  1.  ;;681;;Discharges;;4;;81
  1.  ;;682;;PIP days;;4;;82
  1.  ;;683;;Total visits;;4;;83
  1.  ;;684;;Capital Adjustment;;4;;84
  1.  ;;685;;Patient Interest adjustment;;4;;85
  1.  ;;686;;Statutory Adjustment;;4;;86
  1.  ;;687;;Transfer Amount;;4;;87
  1.  ;;688;;Adj Amt Rep Rec Prior OvrPymt;;21;;88
  1.  ;;689;;Pro Fees Removed from Charges;;4;;89
  1.  ;;690;;Ingredient Cost Adjustment;;4;;90
  1.  ;;691;;Dispensing Fee Adjustment;;3;;91
  1.  ;;692;;Claim Paid In Full;;22;;92
  1.  ;;693;;No Claim level adjustments;;22;;93
  1.  ;;694;;Processed in excess of Charges;;16;;94
  1.  ;;695;;Plan proc not followed;;4;;95
  1.  ;;696;;Non Covered Charge(s);;4;;96
  1.  ;;697;;Pymt IncludeAllow for Diff Srv;;4;;97
  1.  ;;698;;Hosp Must File Medicare Claim;;21;;98
  1.  ;;699;;MSP Adjustment Amount;;4;;99
  1.  ;;701;;Predetermined Antcptd Pymt;;21;;101
  1.  ;;702;;Major Medical Adjustment;;4;;102
  1.  ;;703;;Provider Promotional Discount;;4;;103
  1.  ;;704;;Managed Care Withholding;;4;;104
  1.  ;;705;;Tax Withholding;;4;;105
  1.  ;;706;;Pt Pymt Optn/Elect Not inEffct;;4;;106
  1.  ;;707;;Qualifying srv not identified;;4;;107
  1.  ;;708;;Rent/Purch Guidelines Not Met;;4;;108
  1.  ;;709;;Clm not Covered by this Payer;;4;;109
  1.  ;;710;;Billing Date Precedes DOS;;4;;110
  1.  ;;711;;Prov did not accept assignment;;4;;111
  1.  ;;713;;Pymt Den Srv Prov Outside US;;4;;113
  1.  ;;714;;Proc/Srv Not Approved by FDA;;4;;114
  1.  ;;715;;Proc postponed/cancelled;;4;;115
  1.  ;;716;;Req not met pt indemnification;;4;;116
  1.  ;;717;;Pymt Adj Transp Covrd CloseFac;;4;;117
  1.  ;;718;;Charges Redcd for ESRD Support;;4;;118
  1.  ;;719;;Benefit maximum reached;;4;;119
  1.  ;;720;;Pt Cov by Managed Care Plan;;4;;120
  1.  ;;721;;Indemnification Adjustment;;4;;121
  1.  ;;722;;Psychiatric Reduction;;4;;122
  1.  ;;723;;Payer refund due to ovrpymt;;22;;123
  1.  ;;724;;Payer refund Amt - not our pt;;22;;124
  1.  ;;725;;Pymt adj due to billing errors;;4;;125
  1.  ;;726;;Deductible - Major Medical;;13;;126
  1.  ;;727;;Coinsurance - Major Medical;;14;;127
  1.  ;;728;;Newbrn srv incl w/mother allow;;4;;128
  1.  ;;730;;Claim Submission Fee;;4;;130
  1.  ;;731;;Clm Spec Negotiated Discount;;4;;131
  1.  ;;732;;Pre-Arranged Demo Proj Adj;;4;;132
  1.  ;;733;;Svc line pending further rev;;21;;133
  1.  ;;734;;Tech Fees Removed From Chrgs;;4;;134
  1.  ;;735;;Clm Den Intrm bill Cannot Proc;;4;;135
  1.  ;;736;;Clm Adj Plan Proc Prior Payer;;4;;136
  1.  ;;738;;Clm Den Appeal Proc Not Follow;;4;;138
  1.  ;;739;;Contracted funding agreement;;4;;139
  1.  ;;740;;Pt ID# & Name do not match;;4;;140
  1.  ;;742;;Clm Adj Mnth Medcd Pt Liab Amt;;4;;142
  1.  ;;743;;Portion of Payment Deferred;;21;;143
  1.  ;;744;;Incentive Adjustment;;4;;144
  1.  ;;745;;Premium Pymt Withholding;;4;;145
  1.  ;;746;;Diagnosis invalid for DOS;;4;;146
  1.  ;;747;;Prv Rate Expired/Not on file;;4;;147
  1.  ;;748;;Clm/Srv Rej Info Incomplete;;4;;148
  1.  ;;749;;Lifetime benefit max reached;;4;;149
  1.  ;;750;;PayAdj No Info for Lgth of Svc;;4;;151
  1.  ;;751;;PayAdj No Info for Lgth of Svc;;4;;152
  1.  ;;752;;Info does not support dosage;;4;;153
  1.  ;;753;;Days supply not supported;;4;;154
  1.  ;;754;;PayAdj No Info for Lvl of Svc;;4;;150
  1.  ;;755;;Clm Den Pt Refused Srv/Proc;;4;;155
  1.  ;;756;;Flex Spending Acct Pymnt;;22;;156
  1.  ;;757;;Service/proc result of war;;4;;157
  1.  ;;758;;Pmt Den/Red Outside US;;4;;158
  1.  ;;759;;Srv prov result of terrorism;;4;;159
  1.  ;;760;;Injury is a benefit exclusion;;4;;160
  1.  ;;762;;Property & Casualty Require;;4;;162
  1.  ;;763;;Attachment/Doc not received;;21;;163
  1.  ;;764;;Attachment/Doc not rec timely;;4;;164
  1.  ;;765;;Referral absent/exceeded;;15;;165
  1.  ;;766;;Payer Resp for Processing Over;;4;;166
  1.  ;;767;;Diagnosis(s) not covered;;4;;167
  1.  ;;768;;Ben not available under plan;;4;;168
  1.  ;;769;;Alternate benefit provided;;4;;169
  1.  ;;770;;Type of provider not payable;;4;;170
  1.  ;;771;;Type of prov/fac not payable;;4;;171
  1.  ;;772;;Pymt Adj Specialty Provider;;4;;172
  1.  ;;773;;Svc not prescribd by physician;;4;;173
  1.  ;;774;;Svc not prescribd prior to del;;4;;174
  1.  ;;775;;Prescription is incomplete;;4;;175
  1.  ;;776;;Prescription is not current;;4;;176
  1.  ;;777;;Pymt Den PT Not Met Reqrmts;;4;;177
  1.  ;;778;;Pymt Adj Pt Spend Dn Not Met;;4;;178
  1.  ;;779;;Pymt Adj Pt Waiting Req Not Me;;4;;179
  1.  ;;780;;Pymt Adj Pt Residency Req Not;;4;;180
  1.  ;;781;;Pymt Adj Proc Code Inv DOS;;4;;181
  1.  ;;782;;Pymt Adj Modifier Inv DOS;;4;;182
  1.  ;;783;;Ref Prov not Elig to Refer;;4;;183
  1.  ;;784;;Order Prov not Elig to Order;;4;;184
  1.  ;;785;;Rend Prov not Elig to Prvd Svc;;4;;185
  1.  ;;786;;Change in level of care;;4;;186
  1.  ;;787;;Consumer spending account pymt;;22;;187
  1.  ;;788;;Proc Cov Only for FDA Rec;;4;;188
  1.  ;;789;;NOC/Unlisted Proc Code Used;;4;;189
  1.  ;;790;;Pymt Incl in SNF Qual Stay;;4;;190
  1.  ;;791;;Clm Den Not Work Related No WC;;4;;191
  1.  ;;792;;Non Std ADJ Code Paper RA;;4;;192
  1.  ;;793;;Clm Properly Proc First Time;;22;;193
  1.  ;;794;;Prov not payble for anesthesia;;4;;194
  1.  ;;795;;Pymt Adj Err Refund is oth pyr;;19;;195
  1.  ;;796;;Clm/Svc Den Prior Payor Determ;;4;;196
  1.  ;;797;;Precert/Authorization absent;;4;;197
  1.  ;;798;;Precert/Authorization exceeded;;4;;198
  1.  ;;799;;Rev/Proc Code do not match;;4;;199
  1.  ;;800;;Patient Refund Amount;;19;;A0
  1.  ;;801;;Claim Denied Charges;;4;;A1
  1.  ;;802;;Contractual Adjustment;;4;;A2
  1.  ;;803;;MSP liability met;;4;;A3
  1.  ;;804;;Medicare claim PPS Day Outlier;;4;;A4
  1.  ;;805;;Medicare Clm PPS Cost Outlier;;4;;A5
  1.  ;;806;;PriorHosp 30day transf not met;;4;;A6
  1.  ;;807;;Presumptive Pymt Adjustment;;4;;A7
  1.  ;;808;;Clm Den Ungroupable DRG;;4;;A8
  1.  ;;822;;WC Pymt Den, no other code app;;4;;W2
  1.  ;;823;;Pmt incl w/pmt for other svc;;4;;W3
  1.  ;;824;;WC Med Trtmt Guideline adjstmt;;4;;W4
  1.  ;;825;;Med prov not auth'd for WC;;4;;W5
  1.  ;;826;;Referral not auth'd by attndng;;15;;W6
  1.  ;;827;;Proc not listed/comp svc allwd;;22;;W7
  1.  ;;828;;No pymt due,proc fee is zero;;22;;W8
  1.  ;;829;;Svc not pd under oupt fee schd;;4;;W9
  1.  ;;841;;Payment denied;;4;;Y1
  1.  ;;842;;Payment adjusted;;4;;Y2
  1.  ;;843;;Fee schedule adjustment;;22;;Y3
  1.  ;;851;;Non covered visit;;4;;B1
  1.  ;;852;;Covered Visits;;4;;B2
  1.  ;;853;;Covered charges;;4;;B3
  1.  ;;854;;Late Filing Penalty;;15;;B4
  1.  ;;855;;Guidelines Not Met/Exceeded;;4;;B5
  1.  ;;856;;Pymt Adj Due to Type of Prvdr;;4;;B6
  1.  ;;857;;Prov not cert for proc/svc DOS;;4;;B7
  1.  ;;858;;Altrnt Svc Avail, s/b utilized;;4;;B8
  1.  ;;859;;Srvc Not Covd Pt Enrll Hospice;;4;;B9
  1.  ;;860;;Amt Reduced Portion of Proc pd;;4;;B10
  1.  ;;861;;Clm transfer to proper payer;;4;;B11
  1.  ;;862;;Service not documented in MR;;4;;B12
  1.  ;;863;;Payment made in prev payment;;4;;B13
  1.  ;;864;;Pymt Den 1 VT Per Prov Per Day;;4;;B14
  1.  ;;865;;Pymt Adj Proc Not Pd Separate;;4;;B15
  1.  ;;866;;PymtAdj New Pt Qualifn Not Met;;4;;B16
  1.  ;;867;;Adj Nt Prescr, RX Not Complete;;4;;B17
  1.  ;;868;;Pymt Den Proc/Mod Code Invalid;;4;;B18
  1.  ;;869;;Clm Adj Post Rev Org Finding;;4;;B19
  1.  ;;870;;PymtAdj Proc Prtly by DiffProv;;4;;B20
  1.  ;;871;;Charge red srv by another prov;;4;;B21
  1.  ;;872;;Pymt Adj Based on Diagnosis;;4;;B22
  1.  ;;873;;Pymt Den Prov Fail Profcy Test;;4;;B23
  1.  ;;END