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This variable is contained in the following files: Home Health Agency (Fee-for-Service), Outpatient (Fee-for-Service)
Short SAS Name
REVANSI1
SAS Name
REV_CNTR_1ST_ANSI_CD

The first code used to identify the detailed reason an adjustment was made (e.g. reason for denial or reducing payment).

Comments

This field is populated for those claims that are required to process through Outpatient PPS PRICER software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code '07' Medicare FFS Claims (Version K) Codebook 529 August 2018 and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and forward.

Valid beginning with NCH weekly process date 7/7/00.

Source: NCH

*******EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES******* **************POSITIONS 1 & 2 OF ANSI CODE***************
CodeCode value
CO
Contractual Obligations -- this group code should be used when a contractual agreement between the payer and payee, or a regulatory requirement, re- sulted in an adjustment. Generally, these adjust- ments are considered a write-off for the provider and are not billed to the patient.
CR
Corrections and Reversals -- this group code should be used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim.
OA
Other Adjustments -- this group code should be used when no other group code applies to the adjustment.
PI
Payer Initiated Reductions -- this group code should be used when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments).
PR
Patient Responsibility -- this group should be used when the adjustment represents an amount that should be billed to the patient or insured. This group would typically be used for deductible and copay adjustments.
***********Claim Adjustment Reason Codes*************** ***********POSITIONS 3 through 5 of ANSI CODE**********
CodeCode value
1
Deductible Amount
2
Coinsurance Amount
3
Co-pay Amount
4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
5
The procedure code/bill type is inconsistent with the place of service.
6
The procedure code is inconsistent with the patient's age.
7
The procedure code is inconsistent with the patient's gender.
8
The procedure code is inconsistent with the provider type.
9
The diagnosis is inconsistent with the patient's age.
10
The diagnosis is inconsistent with the patient's gender.
11
The diagnosis is inconsistent with the procedure.
12
The diagnosis is inconsistent with the provider type.
13
the date of death precedes the date of service.
14
The date of birth follows the date of service.
15
Claim/service adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
16
Claim/service lacks information which is needed for adjudication.
17
Claim/service adjusted because requested information was not provided or was insufficient/incomplete.
18
Duplicate claim/service.
19
Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
20
Claim denied because this injury/illness is covered by the liability carrier.
21
Claim denied because this injury/illness is the liability of the no-fault carrier.
22
Claim adjusted because this care may be covered by another payer per coordination of benefits.
23
Claim adjusted because charges have been paid by another payer.
24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
25
Payment denied. Your Stop loss deductible has not been met.
26
Expenses incurred prior to coverage.
27
Expenses incurred after coverage terminated.
28
Coverage not in effect at the time the service was provided.
29
The time limit for filing has expired.
30
Claim/service adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
31
Claim denied as patient cannot be identified as our insured.
32
Our records indicate that this dependent is not an eligible dependent as defined.
33
Claim denied. Insured has no dependent coverage.
34
Claim denied. Insured has no coverage for newborns.
35
Benefit maximum has been reached.
36
Balance does not exceed copayment amount.
37
Balance does not exceed deductible amount.
38
Services not provided or authorized by designated (network) providers.
39
Services denied at the time authorization/pre-certi- fication was requested.
40
Charges do not meet qualifications for emergency/urgent care.
41
Discount agreed to in Preferred Provider contract.
42
Charges exceed our fee schedule or maximum allowable amount.
43
Gramm-Rudman reduction.
44
Prompt-pay discount.
45
Charges exceed your contracted/legislated fee arrangement.
46
This (these) service(s) is(are) not covered.
47
This (these) diagnosis(es) is(are) not covered, missing, or are invalid.
48
This (these) procedure(s) is(are) not covered.
49
These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
50
These are non-covered services because this is not deemed a 'medical necessity' by the payer.
51
These are non-covered services because this a pre-existing condition.
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
53
Services by an immediate relative or a member of the same household are not covered.
54
Multiple physicians/assistants are not covered in this case.
55
Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
56
Claim/service denied because procedure/treatment has not been deemed 'proven to be effective' by payer.
57
Claim/service adjusted because the payer deems the information submitted does not support this level of service, this many services, this length of service, or this dosage.
58
Claim/service adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
59
Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
60
Charges for outpatient services with the proximity to inpatient services are not covered.
61
Charges adjusted as penalty for failure to obtain second surgical opinion.
62
Claim/service denied/reduced for absence of, or exceeded, precertification/authorization.
63
Correction to a prior claim. INACTIVE
64
Denial reversed per Medical Review. INACTIVE
65
Procedure code was incorrect. This payment reflects the correct code. INACTIVE
66
Blood Deductible.
67
Lifetime reserve days. INACTIVE
68
DRG weight. INACTIVE
69
Day outlier amount.
70
Cost outlier amount.
71
Primary Payer amount.
72
Coinsurance day. INACTIVE
73
Administrative days. INACTIVE
74
Indirect Medical Education Adjustment.
75
Direct Medical Education Adjustment.
76
Disproportionate Share Adjustment.
77
Covered days. INACTIVE
78
Non-covered days/room charge adjustment.
79
Cost report days. INACTIVE
80
Outlier days. INACTIVE
81
Discharges. INACTIVE
82
PIP days. INACTIVE
83
Total visits. INACTIVE
84
Capital adjustments. INACTIVE
119
Benefit maximum for this time period has been reached.
120
Patient is covered by a managed care plan. INACTIVE
121
Indemnification adjustment.
122
Psychiatric reduction.
123
Payer refund due to overpayment. INACTIVE
124
Payer refund amount - not our patient. INACTIVE
125
Claim/service adjusted due to a submission/billing error(s).
126
Deductible - Major Medical.
127
Coinsurance - Major Medical.
128
Newborn's services are covered in the mother's allowance.
129
Claim denied - prior processing information appears incorrect.
130
Paper claim submission fee.
131
Claim specific negotiated discount.
132
Prearranged demonstration project adjustment.
133
The disposition of this claim/service is pending further review.
134
Technical fees removed from charges.
135
Claim denied. Interim bills cannot be processed.
136
Claim adjusted. Plan procedures of a prior payer were not followed.
137
Payment/Reduction for Regulatory Surcharges, Assess ments, Allowances or Health Related Taxes.
138
Claim/service denied. Appeal procedures not followed or time limits not met.
139
Contracted funding agreement - subscriber is employed by the provider of services.
140
Patient/Insured health identification number and name do not match.
141
Claim adjustment because the claim spans eligible and ineligible periods of coverage.
142
Claim adjusted by the monthly Medicaid patient liability amount.
A0
Patient refund amount
A1
Claim denied charges.
A2
Contractual adjustment.
A3
Medicare Secondary Payer liability met. INACTIVE
A4
Medicare Claim PPS Capital Day Outlier Amount.
A5
Medicare Claim PPS Capital Cost Outlier Amount.
A6
Prior hospitalization or 30 day transfer requirement not met.
A7
Presumptive Payment Adjustment.
A8
Claim denied; ungroupable DRG.
B1
Non-covered visits.
B2
Covered visits. INACTIVE
B3
Covered charges. INACTIVE
B4
Late filing penalty.
B5
Claim/service adjusted because coverage/program guidelines were not met or were exceeded.
B6
This service/procedure is adjusted when performed/billed by this type of provider, by this type of facility, or by a provider of this specialty.
B7
This provider was not certified/eligible to be paid for this procedure/service on this date of service.
B8
Claim/service not covered/reduced because alternative services were available, and should have been utilized.
B9
Services not covered because the patient is enrolled in a Hospice.
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.
B11
The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
B12
Services not documented in patients' medical records.
B13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14
Claim/service denied because only one visit or consultation per physician per day is covered.
B15
Claim/service adjusted because this procedure/ service is not paid separately.
B16
Claim/service adjusted because 'New Patient' qualifications were not met.
B17
Claim/service 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.
B18
Claim/service denied because this procedure code/ modifier was invalid on the date of service or claim submission.
B19
Claim/service adjusted because of the finding of a Review Organization. INACTIVE
B20
Charges adjusted because procedure/service was partially or fully furnished by another provider.
B21
The charges were reduced because the service/care was partially furnished by another physician. INACTIVE
B22
This claim/service is adjusted based on the diagnosis.
B23
Claim/service denied because this provider has failed an aspect of a proficiency testing program.
W1
Workers Compensation State Fee Schedule Adjustment.