Health Care Services Decision Reason Codes are used to indicate the primary reason for the certification action code assigned as part of a health care services review.
01 Price Authorization Expired Start: 01/10/2001
02 Price authorization no longer required Start: 01/10/2001
03 Product not on the price authorization Start: 01/10/2001
04 Authorized Quantity Exceeded Start: 01/10/2001
05 Special Cost Incorrect Start: 01/10/2001
06 No Credit Allowed Start: 01/10/2001
07 Administrative Cancellation Start: 01/10/2001
08 Unit resale higher than authorized Start: 01/10/2001
09 Out of Network Start: 01/10/2001
0A Testing not Included Start: 01/10/2001
0B Request Forwarded To and Decision Response Forthcoming From an External Review Organization Start: 01/10/2001
0C Authorization/Access Restrictions Start: 01/10/2001
0D Requires PCP authorization Start: 01/10/2001
0E Provider is Not Primary Care Physician Start: 01/10/2001
0F Not Medically Necessary Start: 01/10/2001
0G Level of Care Not Appropriate Start: 01/10/2001
0H Certification Not Required for this Service Start: 01/10/2001
0J Certification Responsibility of External Review Organization Start: 01/10/2001
0K Primary Care Service Start: 01/10/2001
0L Exceeds Plan Maximums Start: 01/10/2001
0M Non-covered Service Start: 01/10/2001
0N No Prior Approval Start: 01/10/2001
0P Requested Information Not Received Start: 01/10/2001
0Q Duplicate Request Start: 01/10/2001
0R Service Inconsistent with Diagnosis Start: 01/10/2001
0S Pre-existing Condition Start: 01/10/2001
0T Experimental Service or Procedure Start: 01/10/2001
0U Additional Patient Information required Start: 01/10/2001
0V Requires Medical Review Start: 01/10/2001
0W Disposition pending review Start: 01/10/2001
0X Service Inconsistent with Provider Type Start: 01/10/2001
0Y Service inconsistent with Patient’s Age Start: 01/10/2001
0Z Service inconsistent with Patient’s Gender Start: 01/10/2001
10 Product/service/procedure delivery pattern (e.g., units, days, visits, weeks, hours, months) Start: 01/10/2001
11 Pricing Start: 01/10/2001
12 Patient is restricted to specific provider Start: 01/10/2001
13 Service authorized for another provider Start: 01/10/2001
14 Plan/contractual guidelines not followed Start: 01/10/2001
15 Plan/contractual geographic restriction Start: 01/10/2001
16 Inappropriate facility type Start: 01/10/2001
17 Time limits not met Start: 02/01/2002
18 Notification received Start: 06/01/2002
19 Cosmetic Start: 06/01/2002
20 Once in a lifetime restriction applies Start: 02/01/2004
21 Transport Request Denied Start: 06/01/2004
22 Ambulance Certification Segment information doesn’t correspond to Transport Address Segment Start: 06/01/2004
23 Mileage cannot be computed based on data submitted Start: 06/01/2004
24 Computed mileage is inconsistent with transport information or service units submitted Start: 06/01/2004
25 Services were not considered due to other errors in the request. Start: 06/06/2010
26 Missing Provider Role Start: 06/05/2011
