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Routine: BARADJRK

BARADJRK.m

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BARADJRK  ;IHS/SD/POT - CREATE ENTRY IN A/R EDI STND CLAIM ADJ REASON ;

 ;;1.8;IHS ACCOUNTS RECEIVABLE;**28**;OCT 26, 2005;Build 92

 ; IHS/SD/CPC HEAT326081 - V1.8 P28 - updated SARs

 ; code cloned from BARADJR7

 ;

EN ; EP

 ; Change Name of these reasons

 S BARD=";;"

 S BARCNT=0

 D BMES^XPDUTL("Updating Adjustment Reasons to A/R Table Entry file Phase 1...")

 F  D CHNGREA2 Q:BARVALUE="END"

 K DIC,DA,X,Y,DIE

 D ^BARVKL0

 Q

 ; ********************************************************************

CHNGREA2 ;

 S BARCNT=BARCNT+1

 S BARVALUE=$P($T(@4+BARCNT),BARD,2)

 Q:BARVALUE="END"

 K DIC,DA,X,Y,DIE

 S DIC="^BARTBL("

 S DIC(0)="M"

 S X=BARVALUE

 D ^DIC

 I +Y>0 D

 .K DIC,DIE,BARNAME

 .S DIE="^BARTBL("

 .S DA=+Y

 .S BARNAME=$P($T(@4+BARCNT),BARD,3)

 .S DR=".01////^S X=BARNAME"

 .D ^DIE

 .D MES^XPDUTL(BARVALUE_$S($L(BARVALUE)=2:"   ",$L(BARVALUE)=1:"    ",1:"  ")_BARNAME)

 Q

 ; ********************************************************************

 ; STANDARD CODE ;; RPMS REASON

 ; ********************************************************************

4 ;;A/R Table Entry file - Edits DIE="^BARTBL("

 ;;15;;Wrkrs comp State Fee Sched Adj;;3;;W1

 ;;17;;Clm Den Insured no Cov for NB;;4;;34

 ;;19;;Non Cov Srv PreExist Condition;;4;;51

 ;;20;;Non Cov Srv Routine Exam;;4;;49

 ;;21;;Chrgs Excd Max Allowable Amt;;4;;42

 ;;23;;Pymt Made to PT/Insrd/Res Prty;;4;;100

 ;;27;;Co-payment;;14;;3

 ;;29;;Deductible;;13;;1

 ;;93;;DRG Weight;;16;;68

 ;;122;;Services Not Covered;;4;;46

 ;;125;;Clm Adj Spans Elig/Inelig Date;;4;;141

 ;;134;;Time Limit for Filing Expired;;4;;29

 ;;135;;Duplicate Claim/Service;;3;;18

 ;;141;;Regulatory surcharge/allowance;;4;;137

 ;;164;;Pymt Den Prior Info Incorrect;;4;;129

 ;;165;;Primary Payer Amount;;4;;71

 ;;166;;Pt cannot be ID'd as insured;;4;;31

 ;;167;;Lifetime max benefit reached;;4;;35

 ;;168;;Disc Agrmt Pref Prov Contract;;4;;41

 ;;169;;Non Cov Srv Not Medically Nec;;4;;50

 ;;178;;Prov Not Elig to Provd Serv/Bl;;4;;52

 ;;180;;Svc not furnished direct to pt;;4;;112

 ;;300;;Incorrect attchmt/documnt rcvd;;4;;250

 ;;301;;Incomplete or deficient docs;;4;;251

 ;;302;;Doc reqd to adjudicate clm/svc;;4;;252

 ;;303;;Sequestration-red in fed pymt;;15;;253

 ;;304;;No bnfts-Submit svcs to med pl;;4;;254

 ;;305;;Clm pending due to litigation;;21;;255

 ;;306;;Not payable per mngd care cont;;4;;256

 ;;307;;Clm pndng during prem grace pd;;21;;257

 ;;308;;Clm not cvrd - pt incarcerated;;4;;258

 ;;401;;ST-mandated rqrmt for property;;22;;P1

 ;;402;;No WC liab-Not wrk rel inj/ill;;4;;P2

 ;;403;;WC case settled, pt resp;;4;;P3

 ;;404;;WC case adjudicated as non-WC;;4;;P4

 ;;405;;Based on payer reas & cust fee;;4;;P5

 ;;406;;Based on entitlement to bnfts;;4;;P6

 ;;407;;Resub w/correct proc code;;22;;P7

 ;;408;;Claim is under investigation.;;22;;P8

 ;;409;;No CPT/HCPCS to describe svc;;4;;P9

 ;;410;;Pmt reduc to zero, litigation;;4;;P10

 ;;411;;Clm pending due to litigation;;21;;P11

 ;;412;;WC fee schedule adjustment;;4;;P12

 ;;413;;Pmt red/den due to WC policies;;4;;P13

 ;;414;;Pmt incl w/pmt for other svc;;4;;P14

 ;;415;;WC Med Trtmt Guideline adjstmt;;4;;P15

 ;;416;;Med prov not auth'd for WC;;4;;P16

 ;;417;;Referral not auth'd by attndng;;15;;P17

 ;;418;;Proc not listed/comp svc allwd;;4;;P18

 ;;419;;No pymt due,proc fee is zero;;4;;P19

 ;;420;;Svc not pd under oupt fee schd;;4;;P20

 ;;421;;TPL Payment denied-MPC/PIP;;4;;P21

 ;;422;;TPL Payment adjusted-MPC/PIP;;4;;P22

 ;;423;;TPL Fee Sch Adjust-MPC/PIP;;4;;P23

 ;;602;;Coinsurance Amount;;14;;2

 ;;604;;Proc code inconst w/mod;;4;;4

 ;;605;;Proc Code/TOB inconst w/POS;;4;;5

 ;;606;;Proc/Rev Code inconst w/pt age;;4;;6

 ;;607;;Proc Code inconst w/pt gender;;4;;7

 ;;608;;Proc Code inconst w/Prov Type;;4;;8

 ;;609;;DX inconst w/pt age;;4;;9

 ;;610;;DX inconst w/pt gender;;4;;10

 ;;611;;DX inconst w/proc;;4;;11

 ;;612;;DX inconst w/Prov Type;;4;;12

 ;;613;;Date of death precedes DOS;;4;;13

 ;;614;;Date of birth follows DOS;;4;;14

 ;;615;;Auth Number missing/invalid;;4;;15

 ;;616;;Clm/Srvc Lacks Info For Adjud;;4;;16

 ;;617;;Pymt Adj Info Incomplete;;4;;17

 ;;619;;Clm Denied work related injury;;4;;19

 ;;620;;Clm Den Injry Covrd Liab Carr;;4;;20

 ;;621;;Inj liability of no-fault ins;;4;;21

 ;;622;;Covd by another payer per COB;;4;;22

 ;;623;;Chrgs pd/adj by another payer;;4;;23

 ;;624;;Chrgs covd by cap agreement;;4;;24

 ;;625;;Pymt Den Stoploss Ded Not Met;;4;;25

 ;;626;;Expnse Incrrd Prior to Coverag;;4;;26

 ;;627;;Expnse Incrrd Aft Cov Termnatd;;4;;27

 ;;628;;Coverage Not in Effect on DOS;;4;;28

 ;;630;;Requirements for elig not met;;4;;30

 ;;632;;Records Indicate Dep Not Elig;;4;;32

 ;;633;;Clm DenInsured No Depend Cove;;4;;33

 ;;636;;Bal Does not Exceed CoPymt Amt;;4;;36

 ;;637;;Bal Does not Exceed Deductible;;4;;37

 ;;638;;Serv Not Auth by Designtd Prov;;4;;38

 ;;639;;Service denied at prior auth;;4;;39

 ;;640;;Criteria for ER/UC not met;;4;;40

 ;;643;;Gramm-Rudman reduction;;4;;43

 ;;644;;Prompt Pay Discount;;4;;44

 ;;645;;Chgs exceed fee schd/max allow;;4;;45

 ;;647;;Dx not Covered/Missing/Invalid;;4;;47

 ;;648;;Procedure Not Covered;;4;;48

 ;;653;;Srv by immed relative not cov;;4;;53

 ;;654;;Mult Prov Not Cov in This Case;;4;;54

 ;;655;;Clm Srv deemed experimental;;4;;55

 ;;656;;Proc not deemed as effective;;4;;56

 ;;657;;Pymt Den Info Submtd Not Suff;;4;;57

 ;;658;;Invalid/inappropriate POS;;4;;58

 ;;659;;Mult surgery/concurrent rules;;4;;59

 ;;660;;Outpt srv w/in inpt proximity;;4;;60

 ;;661;;Failed to obtain sec surg opin;;21;;61

 ;;662;;Pymt Den/Reducd No Precrt Auth;;15;;62

 ;;663;;Correction to Prior Claim;;4;;63

 ;;664;;Denial reversed per Med Review;;22;;64

 ;;665;;Pmt Den/Reducd Proc Code Wrong;;4;;65

 ;;666;;Blood Deductible;;13;;66

 ;;667;;Lifetime Reserve Days;;4;;67

 ;;669;;Day Outlier Amount;;4;;69

 ;;670;;Cost Outlr Adj for Addl Cost;;4;;70

 ;;672;;Coinsurance Day;;14;;72

 ;;673;;Administrative Days;;4;;73

 ;;674;;Indirect Med Educ Adjustment;;4;;74

 ;;675;;Direct Med Educ Adjustment;;4;;75

 ;;676;;Disproportionate Share Adj;;4;;76

 ;;677;;Covered Days;;4;;77

 ;;678;;Non Covered Days/Room Chrg Adj;;4;;78

 ;;679;;Cost Report Days;;4;;79

 ;;680;;Outlier Days;;4;;80

 ;;681;;Discharges;;4;;81

 ;;682;;PIP days;;4;;82

 ;;683;;Total visits;;4;;83

 ;;684;;Capital Adjustment;;4;;84

 ;;685;;Patient Interest adjustment;;4;;85

 ;;686;;Statutory Adjustment;;4;;86

 ;;687;;Transfer Amount;;4;;87

 ;;688;;Adj Amt Rep Rec Prior OvrPymt;;21;;88

 ;;689;;Pro Fees Removed from Charges;;4;;89

 ;;690;;Ingredient Cost Adjustment;;4;;90

 ;;691;;Dispensing Fee Adjustment;;3;;91

 ;;692;;Claim Paid In Full;;22;;92

 ;;693;;No Claim level adjustments;;22;;93

 ;;694;;Processed in excess of Charges;;16;;94

 ;;695;;Plan proc not followed;;4;;95

 ;;696;;Non Covered Charge(s);;4;;96

 ;;697;;Pymt IncludeAllow for Diff Srv;;4;;97

 ;;698;;Hosp Must File Medicare Claim;;21;;98

 ;;699;;MSP Adjustment Amount;;4;;99

 ;;701;;Predetermined Antcptd Pymt;;21;;101

 ;;702;;Major Medical Adjustment;;4;;102

 ;;703;;Provider Promotional Discount;;4;;103

 ;;704;;Managed Care Withholding;;4;;104

 ;;705;;Tax Withholding;;4;;105

 ;;706;;Pt Pymt Optn/Elect Not inEffct;;4;;106

 ;;707;;Qualifying srv not identified;;4;;107

 ;;708;;Rent/Purch Guidelines Not Met;;4;;108

 ;;709;;Clm not Covered by this Payer;;4;;109

 ;;710;;Billing Date Precedes DOS;;4;;110

 ;;711;;Prov did not accept assignment;;4;;111

 ;;713;;Pymt Den Srv Prov Outside US;;4;;113

 ;;714;;Proc/Srv Not Approved by FDA;;4;;114

 ;;715;;Proc postponed/cancelled;;4;;115

 ;;716;;Req not met pt indemnification;;4;;116

 ;;717;;Pymt Adj Transp Covrd CloseFac;;4;;117

 ;;718;;Charges Redcd for ESRD Support;;4;;118

 ;;719;;Benefit maximum reached;;4;;119

 ;;720;;Pt Cov by Managed Care Plan;;4;;120

 ;;721;;Indemnification Adjustment;;4;;121

 ;;722;;Psychiatric Reduction;;4;;122

 ;;723;;Payer refund due to ovrpymt;;22;;123

 ;;724;;Payer refund Amt - not our pt;;22;;124

 ;;725;;Pymt adj due to billing errors;;4;;125

 ;;726;;Deductible - Major Medical;;13;;126

 ;;727;;Coinsurance - Major Medical;;14;;127

 ;;728;;Newbrn srv incl w/mother allow;;4;;128

 ;;730;;Claim Submission Fee;;4;;130

 ;;731;;Clm Spec Negotiated Discount;;4;;131

 ;;732;;Pre-Arranged Demo Proj Adj;;4;;132

 ;;733;;Svc line pending further rev;;21;;133

 ;;734;;Tech Fees Removed From Chrgs;;4;;134

 ;;735;;Clm Den Intrm bill Cannot Proc;;4;;135

 ;;736;;Clm Adj Plan Proc Prior Payer;;4;;136

 ;;738;;Clm Den Appeal Proc Not Follow;;4;;138

 ;;739;;Contracted funding agreement;;4;;139

 ;;740;;Pt ID# & Name do not match;;4;;140

 ;;742;;Clm Adj Mnth Medcd Pt Liab Amt;;4;;142

 ;;743;;Portion of Payment Deferred;;21;;143

 ;;744;;Incentive Adjustment;;4;;144

 ;;745;;Premium Pymt Withholding;;4;;145

 ;;746;;Diagnosis invalid for DOS;;4;;146

 ;;747;;Prv Rate Expired/Not on file;;4;;147

 ;;748;;Clm/Srv Rej Info Incomplete;;4;;148

 ;;749;;Lifetime benefit max reached;;4;;149

 ;;750;;PayAdj No Info for Lgth of Svc;;4;;151

 ;;751;;PayAdj No Info for Lgth of Svc;;4;;152

 ;;752;;Info does not support dosage;;4;;153

 ;;753;;Days supply not supported;;4;;154

 ;;754;;PayAdj No Info for Lvl of Svc;;4;;150

 ;;755;;Clm Den Pt Refused Srv/Proc;;4;;155

 ;;756;;Flex Spending Acct Pymnt;;22;;156

 ;;757;;Service/proc result of war;;4;;157

 ;;758;;Pmt Den/Red Outside US;;4;;158

 ;;759;;Srv prov result of terrorism;;4;;159

 ;;760;;Injury is a benefit exclusion;;4;;160

 ;;762;;Property & Casualty Require;;4;;162

 ;;763;;Attachment/Doc not received;;21;;163

 ;;764;;Attachment/Doc not rec timely;;4;;164

 ;;765;;Referral absent/exceeded;;15;;165

 ;;766;;Payer Resp for Processing Over;;4;;166

 ;;767;;Diagnosis(s) not covered;;4;;167

 ;;768;;Ben not available under plan;;4;;168

 ;;769;;Alternate benefit provided;;4;;169

 ;;770;;Type of provider not payable;;4;;170

 ;;771;;Type of prov/fac not payable;;4;;171

 ;;772;;Pymt Adj Specialty Provider;;4;;172

 ;;773;;Svc not prescribd by physician;;4;;173

 ;;774;;Svc not prescribd prior to del;;4;;174

 ;;775;;Prescription is incomplete;;4;;175

 ;;776;;Prescription is not current;;4;;176

 ;;777;;Pymt Den PT Not Met Reqrmts;;4;;177

 ;;778;;Pymt Adj Pt Spend Dn Not Met;;4;;178

 ;;779;;Pymt Adj Pt Waiting Req Not Me;;4;;179

 ;;780;;Pymt Adj Pt Residency Req Not;;4;;180

 ;;781;;Pymt Adj Proc Code Inv DOS;;4;;181

 ;;782;;Pymt Adj Modifier Inv DOS;;4;;182

 ;;783;;Ref Prov not Elig to Refer;;4;;183

 ;;784;;Order Prov not Elig to Order;;4;;184

 ;;785;;Rend Prov not Elig to Prvd Svc;;4;;185

 ;;786;;Change in level of care;;4;;186

 ;;787;;Consumer spending account pymt;;22;;187

 ;;788;;Proc Cov Only for FDA Rec;;4;;188

 ;;789;;NOC/Unlisted Proc Code Used;;4;;189

 ;;790;;Pymt Incl in SNF Qual Stay;;4;;190

 ;;791;;Clm Den Not Work Related No WC;;4;;191

 ;;792;;Non Std ADJ Code Paper RA;;4;;192

 ;;793;;Clm Properly Proc First Time;;22;;193

 ;;794;;Prov not payble for anesthesia;;4;;194

 ;;795;;Pymt Adj Err Refund is oth pyr;;19;;195

 ;;796;;Clm/Svc Den Prior Payor Determ;;4;;196

 ;;797;;Precert/Authorization absent;;4;;197

 ;;798;;Precert/Authorization exceeded;;4;;198

 ;;799;;Rev/Proc Code do not match;;4;;199

 ;;800;;Patient Refund Amount;;19;;A0

 ;;801;;Claim Denied Charges;;4;;A1

 ;;802;;Contractual Adjustment;;4;;A2

 ;;803;;MSP liability met;;4;;A3

 ;;804;;Medicare claim PPS Day Outlier;;4;;A4

 ;;805;;Medicare Clm PPS Cost Outlier;;4;;A5

 ;;806;;PriorHosp 30day transf not met;;4;;A6

 ;;807;;Presumptive Pymt Adjustment;;4;;A7

 ;;808;;Clm Den Ungroupable DRG;;4;;A8

 ;;822;;WC Pymt Den, no other code app;;4;;W2

 ;;823;;Pmt incl w/pmt for other svc;;4;;W3

 ;;824;;WC Med Trtmt Guideline adjstmt;;4;;W4

 ;;825;;Med prov not auth'd for WC;;4;;W5

 ;;826;;Referral not auth'd by attndng;;15;;W6

 ;;827;;Proc not listed/comp svc allwd;;22;;W7

 ;;828;;No pymt due,proc fee is zero;;22;;W8

 ;;829;;Svc not pd under oupt fee schd;;4;;W9

 ;;841;;Payment denied;;4;;Y1

 ;;842;;Payment adjusted;;4;;Y2

 ;;843;;Fee schedule adjustment;;22;;Y3

 ;;851;;Non covered visit;;4;;B1

 ;;852;;Covered Visits;;4;;B2

 ;;853;;Covered charges;;4;;B3

 ;;854;;Late Filing Penalty;;15;;B4

 ;;855;;Guidelines Not Met/Exceeded;;4;;B5

 ;;856;;Pymt Adj Due to Type of Prvdr;;4;;B6

 ;;857;;Prov not cert for proc/svc DOS;;4;;B7

 ;;858;;Altrnt Svc Avail, s/b utilized;;4;;B8

 ;;859;;Srvc Not Covd Pt Enrll Hospice;;4;;B9

 ;;860;;Amt Reduced Portion of Proc pd;;4;;B10

 ;;861;;Clm transfer to proper payer;;4;;B11

 ;;862;;Service not documented in MR;;4;;B12

 ;;863;;Payment made in prev payment;;4;;B13

 ;;864;;Pymt Den 1 VT Per Prov Per Day;;4;;B14

 ;;865;;Pymt Adj Proc Not Pd Separate;;4;;B15

 ;;866;;PymtAdj New Pt Qualifn Not Met;;4;;B16

 ;;867;;Adj Nt Prescr, RX Not Complete;;4;;B17

 ;;868;;Pymt Den Proc/Mod Code Invalid;;4;;B18

 ;;869;;Clm Adj Post Rev Org Finding;;4;;B19

 ;;870;;PymtAdj Proc Prtly by DiffProv;;4;;B20

 ;;871;;Charge red srv by another prov;;4;;B21

 ;;872;;Pymt Adj Based on Diagnosis;;4;;B22

 ;;873;;Pymt Den Prov Fail Profcy Test;;4;;B23

 ;;END