Medicare contractors are permitted to use the following group codes:
CO Contractual Obligation (provider is financially liable);
CR Correction and Reversal (no financial liability);
OA Other Adjustment (no financial liability); and
PR Patient Responsibility (patient is financially liable).
PR 1 Deductible Amount
PR 2 Coinsurance Amount
PR 3 Co-payment Amount
OA 4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
OA 5 The procedure code/bill type is inconsistent with the place of service.
OA 6 The procedure/revenue code is inconsistent with the patient’s age.
OA 7 The procedure/revenue code is inconsistent with the patient’s gender.
OA 8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
OA 9 The diagnosis is inconsistent with the patient’s age.
OA 10 The diagnosis is inconsistent with the patient’s gender.
OA 11 The diagnosis is inconsistent with the procedure.
OA 12 The diagnosis is inconsistent with the provider type.
OA 13 The date of death precedes the date of service.
OA 14 The date of birth follows the date of service.
CO 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
OA 16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PI 17 Payment adjusted because requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
OA 18 Duplicate claim/service.
OA 19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier.
OA 20 Claim denied because this injury/illness is covered by the liability carrier.
OA 21 Claim denied because this injury/illness is the liability of the no-fault carrier.
CO 22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
PI 23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments
CO 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
PR 25 Payment denied. Your Stop loss deductible has not been met.
PR 26 Expenses incurred prior to coverage.
PR 27 Expenses incurred after coverage terminated.
CO 29 The time limit for filing has expired.
PR 31 Claim denied as patient cannot be identified as our insured.
PR 32 Our records indicate that this dependent is not an eligible dependent as defined.
PR 33 Claim denied. Insured has no dependent coverage.
PR 34 Claim denied. Insured has no coverage for newborns.
PR 35 Lifetime benefit maximum has been reached.
CO 38 Services not provided or authorized by designated (network/primary care) providers.
CO 39 Services denied at the time authorization/pre-certification was requested.
OA 40 Charges do not meet qualifications for emergent/urgent care.
OA 44 Prompt-pay discount.
CO 45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
CO 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CO 50 These are non-covered services because this is not deemed a `medical necessity’ by the payer.
CO 51 These are non-covered services because this is a pre-existing condition
OA 53 Services by an immediate relative or a member of the same household are not covered.
CO 54 Multiple physicians/assistants are not covered in this case .
CO 55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CO 56 Claim/service denied because procedure/treatment has not been deemed `proven to be effective’ by the payer.
CO 58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
OA 59 Charges are adjusted based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)
CO 60 Charges for outpatient services with this proximity to inpatient services are not covered.
OA 61 Charges adjusted as penalty for failure to obtain second surgical opinion.
CO 66 Blood Deductible.
CO 69 Day outlier amount.
CO 70 Cost outlier – Adjustment to compensate for additional costs.
OA 74 Indirect Medical Education Adjustment.
OA 75 Direct Medical Education Adjustment.
CO 76 Disproportionate Share Adjustment.
CO 78 Non-Covered days/Room charge adjustment.
PR 85 Interest amount. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR)
OA 87 Transfer amount.
CO 89 Professional fees removed from charges.
OA 90 Ingredient cost adjustment.
CO 91 Dispensing fee adjustment.
CO 94 Processed in Excess of charges.
OA 95 Benefits adjusted. Plan procedures not followed.
CO 96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PI 97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
OA 100 Payment made to patient/insured/responsible party.
CO 101 Predetermination: anticipated payment upon completion of services or claim adjudication.
CO 102 Major Medical Adjustment.
CO 103 Provider promotional discount (e.g., Senior citizen discount).
OA 104 Managed care withholding.
OA 105 Tax withholding.
OA 106 Patient payment option/election not in effect.
CO 107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
PI 108 Payment adjusted because rent/purchase guidelines were not met.
OA 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CO 110 Billing date predates service date.
CO 111 Not covered unless the provider accepts assignment.
PI 112 Payment adjusted as not furnished directly to the patient and/or not documented.
CO 114 Procedure/product not approved by the Food and Drug Administration.
PI 115 Payment adjusted as procedure postponed or canceled. This change effective 1/1/2008: Payment adjusted as procedure postponed, canceled, or delayed.
OA 116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
CO 117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
OA 118 Charges reduced for ESRD network support.
CO 119 Benefit maximum for this time period or occurrence has been reached.
OA 121 Indemnification adjustment.
OA 122 Psychiatric reduction.
CO 125 Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PR 126 Deductible — Major Medical
PR 127 Coinsurance — Major Medical
CO 128 Newborn’s services are covered in the mother’s Allowance.
CR 129 Payment denied – Prior processing information appears incorrect.
OA 130 Claim submission fee.
OA 131 Claim specific negotiated discount.
OA 132 Prearranged demonstration project adjustment.
OA 133 The disposition of this claim/service is pending further review.
OA 134 Technical fees removed from charges.
CO 135 Claim denied. Interim bills cannot be processed.
OA 136 Claim adjusted based on failure to follow prior payer’s coverage rules. (Use Group Code OA).
OA 137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
CO 138 Claim/service denied. Appeal procedures not followed or time limits not met.
CO 139 Contracted funding agreement – Subscriber is employed by the provider of services.
PR 140 Patient/Insured health identification number and name do not match.
OA 141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
CR 142 Claim adjusted by the monthly Medicaid patient liability amount.
OA 143 Portion of payment deferred.
CR 144 Incentive adjustment, e.g. preferred product/service.
PI 145 Premium payment withholding
CO 146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
OA 147 Provider contracted/negotiated rate expired or not on file.
OA 148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
PR 149 Lifetime benefit maximum has been reached for this service/benefit category.
PI 150 Payment adjusted because the payer deems the information submitted does not support this level of service.
PI 151 Payment adjusted because the payer deems the information submitted does not support this many services.
PI 152 Payment adjusted because the payer deems the information submitted does not support this length of service.
PI 153 Payment adjusted because the payer deems the information submitted does not support this dosage.
PI 154 Payment adjusted because the payer deems the information submitted does not support this day’s supply.
OA 155 This claim is denied because the patient refused the service/procedure.
OA 156 Flexible spending account payments
CO 157 Payment denied/reduced because service/procedure was provided as a result of an act of war.
CO 158 Payment denied/reduced because the service/procedure was provided outside of the United States.
CO 159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.
CO 160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.
OA 161 Provider performance bonus
CO 162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
CR 163 Claim/Service adjusted because the attachment referenced on the claim was not received.
CR 164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion.
CO 165 Payment denied /reduced for absence of, or exceeded referral
PR 166 These services were submitted after this payers responsibility for processing claims under this plan ended.
CO 167 This (these) diagnosis(es) is (are) not covered.
PR 168 Payment denied as Service(s) have been considered under the patient’s medical plan. Benefits are not available under this dental plan
PI 169 Payment adjusted because an alternate benefit has been provided
CO 170 Payment is denied when performed/billed by this type of provider.
CO 171 Payment is denied when performed/billed by this type of provider in this type of facility.
CO 172 Payment is adjusted when performed/billed by a provider of this specialty
CR 173 Payment adjusted because this service was not prescribed by a physician
CO 174 Payment denied because this service was not prescribed prior to delivery
CO 175 Payment denied because the prescription is incomplete
CO 176 Payment denied because the prescription is not current
PR 177 Payment denied because the patient has not met the required eligibility requirements
CR 178 Payment adjusted because the patient has not met the required spend down requirements.
CR 179 Payment adjusted because the patient has not met the required waiting requirements
CR 180 Payment adjusted because the patient has not met the required residency requirements
CR 181 Payment adjusted because this procedure code was invalid on the date of service
CR 182 Payment adjusted because the procedure modifier was invalid on the date of service
CO 183 The referring provider is not eligible to refer the service billed.
CO 184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.
CO 185 The rendering provider is not eligible to perform the service billed.
OA 186 Payment adjusted since the level of care changed
OA 187 Health Savings account payments
CO 188 This product/procedure is only covered when used according to FDA recommendations.
OA 189 “Not otherwise classified” or “unlisted” procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
CO 190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
CO 191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers’ compensation carrier.
OA 192 Non standard adjustment code from paper remittance advice.
CO 193 Original payment decision is being maintained. This claim was processed properly the first time.
PI 194 Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician
PI 195 Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service
PI 197 Payment adjusted for absence of precertification/authorization. This change effective 1/1/2008: Payment adjusted for absence of precertification/authorization/notification.
PI 198 Payment Adjusted for exceeding precertification/ authorization.
OA 199 Revenue code and Procedure code do not match.
PR 200 Expenses incurred during lapse in coverage
PR 201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement. (Use group code PR).
PI 202 Payment adjusted due to non-covered personal comfort or convenience services.
PI 203 Payment adjusted for discontinued or reduced service.
PR 204 This service/equipment/drug is not covered under the patient’s current benefit plan
CO 205 Pharmacy discount card processing fee
OA 206 NPI denial – missing
OA 208 NPI denial – not matched
OA 209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)
PI 210 Payment adjusted because pre-certification/authorization not received in a timely fashion
CO 211 National Drug Codes (NDC) not eligible for rebate, are not covered.
PI A0 Patient refund amount.
OA A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
CO A4 Medicare Claim PPS Capital Day Outlier Amount.
CO A5 Medicare Claim PPS Capital Cost Outlier Amount.
OA A6 Prior hospitalization or 30 day transfer requirement not met.
CO A7 Presumptive Payment Adjustment
OA A8 Claim denied; ungroupable DRG
PR B1 Non-covered visits.
CO B10 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.
OA B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
OA B12 Services not documented in patients’ medical records.
OA B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
CO B14 Payment denied because only one visit or consultation per physician per day is covered.
OA B15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
CO B16 Payment adjusted because `New Patient’ qualifications were not met.
OA B18 Payment adjusted because this procedure code and modifier were invalid on the date of service
OA B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
OA B22 This payment is adjusted based on the diagnosis.
CO B23 Payment denied because this provider has failed an aspect of a proficiency testing program.
CO B4 Late filing penalty.
CO B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
CO B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
CR B8 Claim/service not covered/reduced because alternative services were available, and should have been utilized.
PR B9 Services not covered because the patient is enrolled in a Hospice.
PI W1 Workers Compensation State Fee Schedule Adjustment