first priority health explanation codes

FIRST PRIORITY HEALTH EXPLANATION CODES
002
003
004
005
006
007
010
011
017
018
019
043
044
048
049
054
055
056
057
058
059
060
061
062
063
064
065
066
067
068
069
070
071
072
073
075
105
209
210
332
336
341
342
343
344
345
346
347
348
349
350
351
352
353
354
356
500
501
502
503
504
505
Increased allowable. Provider Liability
Reduced allowable. Provider Liability
Reduced copayment. Member Liability
Increased copayment. Member Liability
Reduced deductible. Member Liability
Increased deductible. Member Liability
Reduced co-insurance. Member Liability
Increased co-insurance. Member Liability
Increased allowable units. Provider Liability
Reduced allowable units. Provider Liability
Disallowed amount. Provider Liability
This Pre-authorization request was denied. Provider Liability
This request for a referral was denied. Member Liability
The allowable amount for this service has been reduced according to ASC multiple procedure guidelines. Provider Liability
The allowable amount for this service has been reduced according to ASC default category guidelines. Provider Liability
Services denied due to being delegated to another entity. Provider Liability
Medicare Supplemental Calculation Applied
The allow AMT for this service has been reduced per M/S guidelines. Provider Liability
FSA Paid Amount Override
Bypass FSA Processing Override
Bypass HRA Processing
The allow AMT for this service has been reduced per M/S guidelines. Provider Liability
HRA Paid Amount override
All FSA dollars were previously paid out
Bypass FSA Runout Period Override
Bypass Duplicate Edit
This is not a covered HRA service.
Not covered under Medical Plan to be paid as HRA Only/E service
Patient Liability Disallow Override
No Pledge Amount for this HealthCare Expense
No Pledge Amount for the Dependent Care Expense
Dependent claim line partially paid. Provider Liability
Funds exhausted, awaiting more contributions.
Additional NetworX Data
Deny All Claim Lines. Provider Liability
Automated HRA Payment Bypassed
COB Disallow
Service is not eligible for this provider. Provider Liability
Payment Reduced, Out of Area Max Reached
ITS SF Adjustment Pend
ITS Referral status override
Wrong Provider Paid. Provider Liability
Wrong Subscriber Paid. Provider Liability
Wrong Payee. Provider Liability
Retroactive Cancellation. Member Liability
Benefits. Member Liability
Duplicate. Provider Liability
Lost/Damaged Check, Stop Payment on Check. Provider Liability
Worker’s Comp. Provider Liability
Medicare. Member Liability
Subrogation. Member Liability
COB. Member Liability
Incorrect Subscriber ID. Provider Liability
Patient Change. Provider Liability
Incorrect Reject. Provider Liability
Incorrect Provider/PCP Data. Provider Liability
Submitting IPA is to related to member’s IPA
Capitated entity charge amount equal 0.00
Prudent Layperson Override
Delegated Claim Entity Override
Capitation Indicator
Capitation Fund
June 2014
Page 1
FIRST PRIORITY HEALTH EXPLANATION CODES
506
507
508
509
510
511
701
702
703
704
705
A01
A02
A1
A10
A11
A12
A13
A14
A15
A16
A17
A18
A19
A2
A20
A21
A22
A23
A24
A25
A26
A27
A28
A29
A3
A30
A31
A32
A33
A34
A35
A4
A5
A6
A7
A8
A9
AAR
ADC
B27
BAA
BAL
BAU
BBE
BL0
BL1
BL2
BL3
BL4
BL5
BL6
Risk Indicator
Delegated UM Entity Override
Capitation Deduct
Opt-out override
Service Area Override
Reimbursable allowable amount
Investigative Procedure Disallow
Cosmetic Procedure Disallow
Outdated Procedure Disallow
Invalid Procedure Disallow
Related Procedure Disallow
Sanction Penalty for Failing to Submit Timely. Provider Liability
REFERRAL REQUIREMENTS NOT MET. MEMBER LIABILITY
DIAGNOSIS, REVENUE & PROCEDURE/MODIFIER CODES INVALID. PROVIDER LIABILITY
TITLE ICD REPORTED. INVALID REVENUE & PROCEDURE/MODIFIER CODES. PROVIDER LIABILITY
TITLE ICD REPORTED. INVALID REVENUE CODE. PROVIDER LIABILITY
TITLE ICD REPORTED. INVALID DIAGNOSIS CODE. PROVIDER LIABILITY
TITLE ICD REPORTED. INVALID REVENUE, PROCEDURE/MODIFIER & DIAGNOSIS. PROVIDER LIABILITY
TITLE ICD REPORTED. INVALID PROCEDURE/MODIFIER AND DIAGNOSIS CODES. PROVIDER LIABILITY
TITLE ICD REPORTED. INVALID REVENUE AND DIAGNOSIS CODES. PROVIDER LIABILITY
ICD PROCEDURE CODING METHOD NOT VALID WITH BILL TYPE. PROVIDER LIABILITY
DX, REVENUE & PROCEDURE/MOD INVALID. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
TITLE ICD. INVALID REV & PROC/MOD. ICD P/C INVALID WITH BILL TYPE. PROVIDER LIABILITY
TITLE ICD. INVALID REVENUE CODE. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
DIAGNOSIS & REVENUE CODES INVALID. PROVIDER LIABILITY
TITLE ICD. INVALID DIAGNOSIS CODE. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
TITLE ICD. INVALID REV, PROC/MOD, DX. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
TITLE ICD. INVALID PROCEDURE/MOD, DX. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
TITLE ICD. INVALID REVENUE, DX. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
DIAGNOSIS & REVENUE CODES INVALID. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
DIAGNOSIS & PROCEDURE/MOD INVALID. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
DIAGNOSIS CODE INVALID. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
PROCEDURE/MOD, REVENUE INVALID. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
REVENUE CODE INVALID. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
PROCEDURE/MOD INVALID. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
DIAGNOSIS & PROCEDURE/MODIFIER CODES INVALID. PROVIDER LIABILITY
TITLE ICD. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
TITLE ICD. INVALID PROCEDURE/MOD. ICD P/C INVALID W/BILL TYPE. PROVIDER LIABILITY
ICD PROCEDURE CODE INVALID ON HCFA 1500. PROVIDER LIABILITY
TITLE ICD. ICD PROC CODE INVALID ON HCFA 1500. PROVIDER LIABILITY
DIAGNOSIS INVALID. ICD PROC CODE INVALID ON HCFA 1500. PROVIDER LIABILITY
ICD P/C INVALID ON LINE LEVEL FOR HCFA 1450. PROVIDER LIABILITY
DIAGNOSIS IS INVALID. PROVIDER LIABILITY
PROCEDURE/MODIFIER & REVENUE CODE INVALID. PROVIDER LIABILITY
REVENUE CODE INVALID. PROVIDER LIABILITY
PROCEDURE/MODIFIER CODE INVALID. PROVIDER LIABILITY
TITLE ICD REPORTED. PROVIDER LIABILITY
TITLE ICD REPORTED. INVALID PROCEDURE/MODIFIER CODE. PROVIDER LIABILITY
Payment was Automatically reduced for Recovery of Overpayments or Manual Reductions. Provider Liability
Average Daily Charges Stoploss Provision Invoked
Multichannel laboratory reimbursement. Provider Liability
BALANCE BILL. PROVIDER LIABILITY
Balance bill. Provider Liability
BALANCE BILL. PROVIDER LIABILITY
DIAGNOSIS NOT APPROPRIATE WITH PROCEDURE BILLED. PROVIDER LIABILITY
MEETS/EXCEEDS THE ASD BENEFIT LIMIT FOR SERVICE RENDERED. MEMBER LIABILITY
MEETS/EXCEEDS THE BENEFIT LIMIT FOR THE SERVICE RENDERED. MEMBER LIABILITY
ANNUAL INDIVIDUAL PREFERRED COINSURANCE MAXIMUM MET
ANNUAL INDIVIDUAL NON-PREFERRED COINSURANCE MAXIMUM MET
ANNUAL FAMILY PREFERRED COINSURANCE MAXIMUM MET
ANNUAL FAMILY NON-PREFERRED COINSURANCE MAXIMUM MET
PREFERRED LIFETIME BENEFIT MAXIMUM MET. MEMBER LIABILITY
June 2014
Page 2
FIRST PRIORITY HEALTH EXPLANATION CODES
BL7
BL8
BM0
BM1
CBI
CBN
CDD
CG0
CG1
CG2
CG3
CG4
CG5
COB
CPD
CVX
DAP
DCG
DGE
DIS
DP0
DP1
DP2
DP3
DP4
DP5
DWP
E01
F01
F02
F03
F04
F05
F06
F07
F08
F09
GLB
IAA
IAC
IAD
IAN
IAU
IAX
IN
INH
IPR
ISS
J01
J02
J03
J04
J05
J06
J07
J08
J09
J10
L01
LS2
NON-PREFERRED LIFETIME BENEFIT MAXIMUM MET. MEMBER LIABILITY
ANNUAL INDIVIDUAL COPAY MAXIMUM MET
INDIVIDUAL ANNUAL OUT OF POCKET MAXIMUM MET.
FAMLY ANNUAL OUT OF POCKET MAXIMUM MET.
COB Information not received. Member Liability
Primary Carrier Payment Information Required. Member Liability
This claim is a duplicate to a previously submitted claim. Provider Liability
This dental service is not covered under the plan. Member Liability
This is not a covered dental service under the plan. Member Liability
The charge exceeds the covered amount for the dental service. Provider Liability
Covered amount greater than category allowed amount plus related dental history. Provider Liability
Covered counter greater than category allow counter. Provider Liability
Covered counter greater than category allowed counter plus related dental history. Provider Liability
Paid Limit Accumulator has been altered due to a COB Adjustment. Provider Liability
Possible Claim Duplicate. Provider Liability
Coverage Exclusion. Member Liability
Originally submitted procedure replaced due to benefit plan restrictions. Provider Liability
Override Dental Category
Override Age Limitation
A discount has been applied. A discount has been taken on this claim. Provider Liability
Patient age differs from normative established for this dental procedure. Provider Liability
This dental procedure is not valid for this tooth/teeth. Provider Liability
The charge exceeds the covered amount for the dental service. Provider Liability
Covered amount greater than procedure allowed amount plus related dental claim history (including current claim).
Provider Liability
Covered counter greater than procedure allow counter. Provider Liability
Covered counter greater than procedure allowed counter and related dental history (including current claim).
Provider Liability
Override Dental Category Waiting Period
PLEASE RESUBMIT CLAIM WITH PRIMARY CARRIERS EXPLANATION OF BENEFITS. MEMBER LIABILITY
SERVICES WERE BILLED ON INCORRECT CLAIM FORM TYPE, PLEASE RESUBMIT. PROVIDER LIABILITY
RESUBMIT WITH LEGIBLE PHYSICIAN NOTES. PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT DATE OF SERVICE BILLED. PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT LEVEL OF SERVICE BILLED. PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT PROVIDER BILLING. PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT MEDICAL NECESSITY. PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT PROCEDURE BILLED. PROVIDER LIABILITY
SERVICE(S) DENIED NOT MEDICALLY NECESSARY. MEMBER LIABILITY
THIS SERVICE IS NOT COVERED FOR THE DIAGNOSIS REPORTED. MEMBER LIABLITY
Payment included in global/contracted rate. Provider Liability
ITS LIL allowable amount. Provider Liability
ITS LIL co-pay amount. Member Liability
ITS LIL deductible. Member Liability
ITS LIL coinsurance amount. Member Liability
ITS LIL allowable units. Provider Liability
ITS LIL disallow amount. Provider Liability
Inlier Pricing. Provider Liability
ITS No Hold Harmless Allowable Override. Provider Liability
ITS Private Room Non-Covered Amount.
This is not a covered service for this member. Member Liability
DOES NOT MEET CRITERIA. PROVIDER LIABILITY
THIS CLAIM IS A DUPLICATE TO A CLAIM PAID ON THE PHARMACY SYSTEM. PROVIDER LIABILITY
DOES NOT MEET CRITERIA. HCT EXCEEDS GUIDELINES. PROVIDER LIABILITY
NO PRIOR AUTHORIZATION APPROVED FOR SYNAGIS. PROVIDER MUST SUBMIT PA. PROVIDER LIABILITY
NDC # MISSING/INVALID. PLEASE RESUBMIT WITH VALID NDC NUMBER. PROVIDER LIABILITY
NOT COVERED AS MEDICAL; SUBMIT TO PHARMACY CARRIER. PROVIDER LIABILITY
NOT COVERED AS MEDICAL; SUBMIT TO PHARMACY CARRIER. PROVIDER LIABILITY
ALLERGY SERUM MAY BE COVERED UNDER PHARMACY BENEFIT. MEMBER LIABILITY
SERVICE REQUIRES PRIOR AUTHORIZATION; NO AUTHORIZATION ON FILE. PROVIDER LIABILITY
DUPLICATE SERVICE NOT ELIGIBLE FOR PAYMENT, SUBMTED BY OTHER ENTITY. PROVIDER LIABILITY
NON-DESIGNATEE LAB PROVIDER. PROVIDER LIABILITY
Stoploss based on charge
June 2014
Page 3
FIRST PRIORITY HEALTH EXPLANATION CODES
M01
M02
M03
M04
M05
M06
M07
M08
M09
M10
M11
M12
M13
M14
M15
M16
M17
M18
M19
M20
M21
M22
M23
M24
M25
M26
M27
M28
M29
M30
M34
M36
M38
M40
M41
M42
M44
M45
M46
M47
M48
M49
M50
M51
M52
M53
M54
M55
M56
M57
M58
M59
M60
M61
M62
M63
M64
M65
M66
M67
M68
M69
SERVICES DENIED BY MEDICAL POLICY REVIEW (PACE). PROVIDER LIABILITY
NOT COVERED PER THE MEMBERS CONTRACT. MEMBER LIABILITY
RESUBMIT WITH LEGIBLE PHYSICIAN NOTES. PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT DATE OF SERVICE BILLED. PROVIDER LIABILITY
PROC CAN ONLY BE PERFORMED ONCE PER DATE OF SERVICE PER PACE. PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT LEVEL OF SERVICE (PACE). PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT PROVIDER BILLING. PROVIDER LIABILITY
DOCUMENTATION DOES NOT SUPPORT NECESSITY (PACE). PROVIDER LIABILITY
COSMETIC SERVICES ARE NOT A COVERED BENEFIT. MEMBER LIABILITY
DOCUMENTATION DOES NOT SUPPORT PROCEDURE BILLED (PACE). PROVIDER LIABILITY
SERVICES BILLED IN ERROR, A VALID CODE EXISTS. PROVIDER LIABILITY
MEDICAL DIRECTOR DENIED SERVICES (PACE). PROVIDER LIABILITY
SERVICES DENIED PER MEDICAL DIRECTOR. MEMBER LIABILITY
PACE REVIEW. PLEASE RESUBMIT CLAIM WITH NOTES. PROVIDER LIABILITY
MEDICAL POLICY REVIEW, PLEASE RESUBMIT CLAIM WITH NOTES. PROVIDER LIABILITY
SERVICES DENIED NOT MEDICALLY NECESSARY. MEMBER LIABILITY
DENIED AS A DUPLICATE AFTER CLIN. COORDINATOR REVIEW (PACE). PROVIDER LIABILITY
THIS SERVICE IS NOT COVERED FOR THE DIAGNOSIS REPORTED. MEMBER LIABILITY
SERVICES PROVIDED BY A PHYSICIAN’S ASSISTANT ARE INELIGIBLE. PROVIDER LIABILITY
SERVICES PROVIDED BY A NURSE ARE INELIGIBLE FOR PAYMENT. PROVIDER LIABILITY
A PREVIOUS PAYMENT INCLUDED PAYMENT FOR THIS SERVICE. PROVIDER LIABILITY
THIS SERVICE IS INCLUDED IN INP ADMISSION ALLOWANCE. PROVIDER LIABILITY
PAYMENT FOR THESE SERVICES ARE INCLUDED IN THE TRANSPORT PAYMENT. PROVIDER LIABILITY
THIS SERVICE WAS PROVIDED BY AN INELIGIBLE PROVIDER. PROVIDER LIABILITY
THIS DIAGNOSIS IS INVALID WHEN BILLED WITH THIS PROCEDURE (PACE). PROVIDER LIABILITY
PROCEDURE CODES BILLED DO NOT MATCH PRE-AUTH CODES. RESUBMIT CLAIM. PROVIDER LIABILITY
MEDICAL DIRECTOR DEEMED SERVICE EXPERIMENTAL. SERVICE NOT COVERED. MEMBER LIABILITY
DME CODE OR CODE/MOD COMBO DOES NOT MATCH PRE-AUTH PER PACE. PROVIDER LIABILITY
SERVICES DENIED NOT MEDICALLY NECESSARY (PACE). PROVIDER LIABILITY
THIS IS A BILLING ERROR, PER MED POLICY REVIEW. PROVIDER LIABILITY
NUMBER OF UNITS BILLED FOR THIS PROC EXCEEDS ALLOWABLE UNITS PER PACE. PROVIDER LIABILITY
UNITS BILLED EXCEED THE ALLOWABLE UNITS FOR THIS SERVICE PER PACE. PROVIDER LIABILITY
DUP REVIEW-APPROVE PAYMENT. PROVIDER LIABILITY
DIAGNOSIS NOT APPROPRIATE WITH PROCEDURE BILLED PER PACE. PROVIDER LIABILITY
NON-COVERED SERVICES PER MEDICAL POLICY. MEMBER LIABILITY
NON-COVERED SERVICES PER MEDICAL POLICY (PACE). PROVIDER LIABILITY
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0012
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0146
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0070
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0158
SERVICE NOT COVERED WITH DIAGNOSIS REPORTED. MEMBER RESPONSIBLE FOR CHARGES #490-0118
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0118
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0035
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0150
COSMETIC SERVICES ARE NOT COVERED. MEMBER IS RESPONSIBLE #490-0027
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0163
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0163 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0006
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0025
SERVICE NOT COVERED WITH DIAGNOSIS REPORTED. MEMBER IS RESPONSIBLE #490-0025
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMER IS RESPONSIBLE #490-0018
SERVICE NOT COVERED WITH DIAGNOSIS REPORTED. MEMBER IS RESPONSIBLE #490-0018
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0077
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0147
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0136
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0138
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0136
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0132
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0134
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0137
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0139
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0140
June 2014
Page 4
FIRST PRIORITY HEALTH EXPLANATION CODES
M70
M71
M72
M73
M74
M75
M76
M77
M78
M79
M80
M81
M82
M83
M84
M85
M86
M87
M88
M89
M90
M91
M92
M93
M94
M95
M96
M97
M98
M99
MA1
MA2
MA3
MA4
MA5
MA6
MA7
MA8
MA9
MB0
MB1
MB2
MB3
MB4
MB5
MB6
MB7
MB8
MB9
MC0
MC1
MC2
MC3
MC4
MC5
MC6
MC7
MC8
MC9
MD0
MD1
MD2
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0108
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0108 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0083
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0083
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0083 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0125
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0154
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0072
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0072
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0072 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0088
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0023
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0023
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0023 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0021
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0153
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0141
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0164
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0160
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT REPSONSIBLE #490-0160 Provider Liability
SERVICE NOT COVERED WITH DIAGNOSIS REPORTED. MEMBER IS RESPONSIBLE #490-0010
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0148
COSMETIC SERVICES ARE NOT COVERED. MEMBER IS RESPONSIBLE #490-0151
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0145
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0157 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0131
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0127
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0002
NOT COVERED PER POLICY. MEMBER IS RESPONSIBLE #490-0149
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER NOT RESPONSIBLE #490-0152 Provider Liability
MEDICAL DIRECTOR DENIAL. MEMBER IS RESPONSIBLE #490-0092
MEDICAL DIRECTOR DENIAL. MEMBER NOT RESPONSIBLE #490-0092 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0165
NOT COVERED PER POLICY. MEMBER IS RESPONSIBLE. #490-0161
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0016
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0157
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0144
NOT COVERED PER POLICY. MEMBER IS RESPONSIBLE. #490-0035
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0035
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0069
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0168
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0165 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0152
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0120
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0120
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0120 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0001
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0089
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0126
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0123
SERVICE DENIED NOT MEDICALLY NECESSARY, MEMBER IS RESPONSIBLE #490-0123
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0123 Provider Liability
MED DIRECT DEEMED SERVICE EXPER/INVEST. MEMBER IS RESPONSIBLE #490-0168
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0168
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0168 Provider Liability
SERVICE DENIED NOT MEDICALLY NECESSARY MEMBER NOT RESPONSIBLE #490-0118 Provider Liability
SERVICE DENIED NOT MEDICALLY NECESSARY MEMBER NOT RESPONSIBLE #490-0012 Provider Liability
MED DIRECTOR DEEMED SVC EXP. MEMBER NOT RESPONSIBLE #490-0152 Provider Liability
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0170 Provider Liability
MED DIRECTOR DEEMED SERVICE EXP/INVEST. MEMBER IS RESPONSIBLE #490-0170
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0171 Provider Liability
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESPONSIBLE #490-0171
June 2014
Page 5
FIRST PRIORITY HEALTH EXPLANATION CODES
MD3
MD4
MD5
MD6
MLN
MSA
MSD
MSU
MU1
MU2
MUT
N01
N02
N03
N04
N05
N06
N09
N10
N11
N12
N13
N14
N15
N16
N17
N19
N25
N26
N27
N29
N30
N50
N51
N52
N53
N54
N55
N56
N57
N58
N59
N60
N61
N62
N63
N64
N65
N66
N67
N68
N69
N71
N73
N74
N75
N76
N77
N78
N79
N80
N81
MEDICAL DIRECTOR DEEMED SERVICE EXPERIMENTAL/INVESTIGATIONAL. MEMBER IS RESPONSIBLE #490-0171
SERVICE DENIED NOT MEDICALLY NECESSARY. MEMBER NOT RESPONSIBLE #490-0035 Provider Liability
SERVICE NOT COVERED WITH DIAGNOSIS REPORTED. MEMBER NOT RESPONSIBLE #490-0077 Provider Liability
SERVICE NOT COVERED WITH DIAGNOSIS REPORTED. MEMBER IS NOT RESPONSIBLE #490-0144 Provider Liability
Please resubmit with a primary dx code. Provider Liability
THE ALLOW AMT FOR THIS SERVICE HAS BEEN REDUCED PER M/S GUIDELINES. PROVIDER LIABILITY
The allow AMT for this service has been reduced per M/S guidelines. Provider Liability
THE ALLOW AMT FOR THE SERVICE HAS BEEN REDUCED PER M/S GUIDELINES. PROVIDER LIABILITY
UNABLE TO DETERMINE THE UNLISTED SERVICE BILLED. PROVIDER LIABILITY
SERV CONSIDERED PART OF ANOTHER SERV. SEPARATE PMT NOT TO BE MADE (PACE). PROVIDER LIABILITY
Override Medical Utilization Edits
PROC IS CONSIDERED INCIDENTAL TO OR PART OF THE PRIM PROC PER PACE. PROVIDER LIABILITY
THIS PROC IS CONSIDERED REDUNDANT TO THE PRIMARY PROCEDURE PER PACE. PROVIDER LIABILITY
This procedure is considered secondary to the primary procedure. Provider Liability
THE SERVICE IS CONSIDERED PART OF THE ORIG SURG PROCEDURE PER PACE. PROVIDER LIABILITY
THIS SERVICE IS NOT COVERED ON THE SAME DAY AS A SURG PROC PER PACE. PROVIDER LIABILITY
This procedure does not normally require the service of assist surg. Provider Liability
Cosmetic services are not a covered benefit. Member Liability
Med Director deemed this proc experimental. Services are not covered. Member Liability
THIS PROCEDURE IS NO LONGER CONSIDERED CLINICALLY EFFECTIVE PER PACE. PROVIDER LIABILITY
This procedure contains an Info, Issue or Review Message
This procedure is not a covered service under your plan. Provider Liability
Invalid gender for procedure. Resubmit with appropriate code. Provider Liability
This service is not normally performed for members in this age range. Provider Liability
SERV NOT NORMALLY PERFORMED FOR MEMBER IN THIS AGE RANGE PER PACE. PROVIDER LIABILITY
This service is not covered when performed in this setting. Provider Liability
This service is not covered when billed with diagnosis reported. Member Liability
These charges were rebundled/combined into prim procedure. Provider Liability
Pretreatment Procedure Disallow. Provider Liability
Invalid Modifier Disallow. Provider Liability
Clinical Daily Maximum Exceeded
Lifetime Maximum Exceeded
Current Procedure Rebundle. Provider Liability
History Procedure Rebundle. Provider Liability
Duplicate Uni or Bilateral Procedure. Provider Liability
Dup History Uni or Bilateral Procedure. Provider Liability
Daily or Lifetime Max Occurrence
History Daily/Lifetime Max Occurrence. Member Liability
Duplicate Procedure Submitted. Provider Liability
History Dup Procedure Submitted. Provider Liability
History Mutually Exclusive Procedure
History Incidental Procedure
Assistant Surgeon Sometimes Required
Age Conflict Replaced Procedure
Gender Conflict Replaced Procedure
History Procedure Added Line Rebundle. Provider Liability
History PreOp Conflict within 1 Day
History PostOP Conflict within 90 Days
History Medical Visit Conflict
New Pt Visit Conflict Procedure
Intensity of Service Conflict
Duplicate Component Billing Conflict Current or History
Multiple Component Billing Conflict
Third Party Liability Potential. Member Liability
SmartSuspense edit
History SmartSuspense edit
Invalid Procedure Modifier Combination
Invalid Modifier
Invalid Diagnosis Code
Units Expansion Failed
History Incidental Procedure
Submitted diagnoses may not support this procedure.
June 2014
Page 6
FIRST PRIORITY HEALTH EXPLANATION CODES
N82
N83
N84
N85
N86
N87
N88
N89
N91
N92
N93
N94
N95
N96
O25
OAS
OPC
OUT
P02
P03
P05
P50
PAA
PAC
PAH
PAI
PAK
PAL
PAP
PAR
PCD
PDA
PDC
PDD
PDP
PE0
PEN
PEO
PEX
PFC
PFS
PFU
PFV
PFW
PGA
PGD
PGE
PGO
PGP
PGR
PHH
PIM
PIX
PLA
PLC
PLE
PLP
PMI
PMM
PMP
PMX
PPA
Submitted diagnoses for this procedure monitored.
Facets ClaimCheck N83
Facets ClaimCheck N84
Facets ClaimCheck N85
Facets ClaimCheck N86
Facets ClaimCheck N87
Facets ClaimCheck N88
Facets ClaimCheck N89
CCI Incidental Procedure
History CCI Incidental Procedure
CCI Mutually Exclusive Procedure
History CCI Mutually Exclusive Procedure
Assistant at Surgery Procedure
McKesson User Defined Disallow
Charges Combd due to Dent Clin Edit
This service is not normally covered for members in this age range. Member Liability
Override PCA Disallow
Outlier Pricing. Provider Liability
Visit consists of all Never Pay or Stand Alone. Provider Liability
Service is Never Pay. Provider Liability
Service is Carve Out. Provider Liability
Present On Admission Indicator required but is not valid.
This charge exceeds the contracted amount for this service. Provider Liability
The charge exceeds the allowable amount for this service. Provider Liability
APC RATE. PROVIDER LIABILITY
The charges exceed the contracted amount for this service. Provider Liability
The charges exceed the contracted amount for this service. Provider Liability
The charges exceed the contracted rate for this service. Provider Liability
The charges exceed the contracted rate for this service. Provider Liability
The charge exceeds the contracted amount for this service. Provider Liability
A service pricing disallow has been applied to this line-item. Provider Liability
The charge has been reduced based on a discount arrangement with the provider of service. Provider Liability
The charge has been reduced based on a discount arrangement with the provider of service. Provider Liability
The charge has been reduced based on a discount arrangement with the provider of service. Provider Liability
The charge has been reduced based on a discount arrangement with the provider of service. Provider Liability
The charge exceeds the allowable amount for this service. Provider Liability
This service has been reduced due to lack of compliance with Plan requirements. Provider Liability
The charge exceeds the contracted amount for the service. Provider Liability
External Pricing Disallow. Provider Liability
The charge exceeds the scheduled R&C amount for this procedure. Provider Liability
The charge exceeds the allowable amount for this service. Provider Liability
The charge exceeds the allowable amount for this service. Provider Liability
The charge exceeds the allowable amount for this service. Provider Liability
The charge exceeds the allowable amount for this service. Provider Liability
The charge exceeds the DRG amount for this confinement. Provider Liability
The charge exceeds the DRG amount for this confinement. Provider Liability
The charge exceeds the DRG rate for this confinement. Provider Liability
The charge exceeds the DRG amount for this confinement. Provider Liability
The charge exceeds the DRG amount for this confinement. Provider Liability
The charge exceeds the DRG amount for this confinement. Provider Liability
Hold Harmless Payment Applied
ITS Medicare Pricing Disallow
ITS SF Pricing Disallow
Average Daily Charges Stoploss Met
The Medicare Limiting Charge was Applied. Provider Liability
Encounter Units applied for this service. Provider Liability
Percent Threshold Stoploss Met
Procedure Modifier Combination Invalid
Minimum Provision
Price Adjusted Due to Additional Line Item Modifiers. Provider Liability
Maximum Provision
PACKAGED APC LINE. Provider Liability
June 2014
Page 7
FIRST PRIORITY HEALTH EXPLANATION CODES
PPC
PPG
PS
PS0
PS1
PS2
PSB
PSC
PSM
PSN
PSR
PSS
PSU
PSV
PSW
PTR
PU0
PU1
PU2
PU3
PU4
PU5
PX1
PX2
PX3
PX4
PX5
PX6
PX7
PX8
PX9
PXA
PXB
PXC
PXD
PXE
PXF
PXG
PXH
PXI
PXJ
PXK
PXL
PXM
PXN
PXO
PXP
PXV
PXW
Q14
Q15
Q17
Q18
RBN
RNP
RWD
S10
S11
S12
S13
S14
S15
Exceeds the Ambulatory Payment Classification (APC) rate. Provider Liability
Exceeds APG rate for the line item
The charge exceeds the allowable amount for the service. Provider Liability
This service is not a covered benefit by contract. Member Liability
The charge exceeds the allowable amount for this service. Member Liability
Meets/exceeds the maximum number of units for this service. Member Liability
The charge exceeds the schedule amount for this service. Provider Liability
The charge exceeds the usual and customary amount for this procedure. Provider Liability
The charge exceeds the allowable amount for the service. Provider Liability
SERVICES ARE NON COVERED. PROVIDER LIABILITY
The charge exceeds the allowable rate for the service. Provider Liability
The charge exceeds the allowable rate for this service. Provider Liability
The charge exceeds the allowable rate for this service. Provider Liability
The charge exceeds the allowable amount for this service. Provider Liability
The charge exceeds the allowable rate for this service. Provider Liability
Line Item Reduced Due to Procedure Tiers Calculation. Provider Liability
Unknown
International Units
Grams
Milligrams
Milliliters
Units
Pricing will be manually calculated and entered. Provider Liability
Pricing is Cost. Provider Liability
Pricing is cost plus 10% of the cost. Provider Liability
Pricing=cost + 999.99% of cost. If cost not submitted, pricing=chgs. Provider Liability
If cost exceeds $300.00, pricing is cost plus 10% of the cost. Provider Liability
Cost + Pct w/Threshold or No Cost Chrg. Provider Liability
Pricing is cost. If no cost is submitted, pricing is charge. Provider Liability
If the cost exceeds $1,000.00, pricing is cost. Provider Liability
Discount Excess Days. Provider Liability
Discount + Per Diem. Provider Liability
ASC Grouper, 8 Lv
ASC Grouper, Exception Amount
ASC Grouper, Exception Amount & Percent
ASC Grouper, Except Amount & Percent with Max
ASC Grouper, Exception Pct
ASC Grouper, Exception Percent w/Max
ASC Grouper, 9 Lv
ASC Grouper, 10 Lv
Anesthesia Schedule. Provider Liability
Anesthesia Schedule, 2 Lvl Time. Provider Liability
APC w/Base Rate
ASC Except Amount & Percent w/Proc Max
NetworX Std Fee Schedule
Service + Cost Less Percentage. Provider Liability
Service + Cost Plus Percentage. Provider Liability
Dental Fee Schedule
ASC Grouper, 12 Lv
BENEFIT ADAPTATION CM
BENEFIT ADAPTATION CM
MEDICAL DIRECTOR APPROVAL
MEDICAL DIRECTOR APPROVAL
Rebundle Edit. Provider Liability
New Patient Replacement Edit. Provider Liability
A risk withhold has been applied to this line-item. Provider Liability
The member’s coverage was not in effect on the date services were provided. Member Liability
The member’s coverage was not in effect on the date services were provided. Member Liability
The member’s coverage was not in effect on the date services were provided. Member Liability
Member’s coverage was not in effect on the date the service was provided. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
More than one class/plan entry found. Member Liability
June 2014
Page 8
FIRST PRIORITY HEALTH EXPLANATION CODES
S16
S17
S1A
S1B
S1C
S1D
S1E
S1F
S1G
S2
S20
S21
S22
S23
S24
S25
S3
S4
S5
S6
S7
S8
S9
S?
SB
SC
SD
SE
SF
SG
SL
SM
SN
SO
SP
SPD
SQ
SS
ST
SW
TBD
TF0
TF1
TR0
TR1
TR2
TR3
TR4
TR5
TR6
UAS
UD
UM0
UM1
UM2
UM4
UTM
V01
V02
VBB
X01
No plan selection event found. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
Bill not on file. Member Liability
The member’s coverage was not in effect on the date the service was provided. Provider Liability
The member’s coverage was not in effect on the date the services were provided. Member Liability
The member’s coverage was not in effect on the date the services were provided. Member Liability
The member’s coverage was not in effect on the date the services were provided. Member Liability
The member’s coverage was not in effect on the date the services were provided. Member Liability
Part A or Part B of Medicare is not active for this member. Member Liability
A hold status has been placed on this subscriber and related members. Member Liability
The member’s coverage was not in effect on the date the service was provided. Provider Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
Member not eligible for product category. Member Liability
The member’s age is beyond the limiting age under the plan. Member Liability
The member’s age is beyond the limiting age under the plan. Member Liability
The member’s age is beyond the limiting age of the plan. Member Liability
The member’s coverage was not in effect on the date the service was provided. Member Liability
The member was not eligible for coverage on the date the service was provided. Check eligibility data for a valid event.
Member Liability
The patient is not a covered member under the plan. (Subscriber & Spouse) Member Liability
The patient is not a covered member under the plan. (Subscriber only) Member Liability
The patient is not a covered member under the plan. (Subscriber & Dependent Child(ren) Member Liability
The patient is not a covered member under the plan. (Spouse and dependents) Member Liability
The patient is not a covered member under the plan. (Spouse only) Member Liability
The patient is not a covered member under the plan. (Dependents only) Member Liability
Member not eligible for benefits. (Retired) Member Liability
Member not eligible for benefits. (Deceased) Provider Liability
Member not eligible for benefits. (Non-eligible) Member Liability
Member not eligible for benefits. (Termination ineligible) Member Liability
Member not eligible for benefits. (Termination Non payment of premium) Member Liability
Supplemental Discount.
Member not eligible for benefits. (Termination – Divorce) Member Liability
MEMBER NOT ELIGIBLE FOR BENEFITS. (Separation – Member Termination) MEMBER LIABILITY
Member not eligible for benefits. (Termination) Member Liability
Member not eligible for benefits. (Termination - COBRA) Member Liability
ITS Private Room Non-Covered Amount. Member Liability
This claim was submitted after the claim filing limit. Provider Liability
Claim submitted after filing limit. Provider Liability
This service is not covered under the plan. Member Liability
This is not a covered service under the plan. Member Liability
The benefit limit has been exceeded. Member Liability
Covered amount greater than service allowed amount plus related history amount. Provider Liability
Covered counter greater than service allow counter. Provider Liability
Covered counter greater than service allowed counter and related history counter. Provider Liability
Payment is reduced by amount paid by another carrier. Provider Liability
The member was not covered under the plan on the date the service was provided. Member Liability
Amount disallowed by Utilization Management. Provider Liability
Services were disallowed by Utilization Management. Provider Liability
Units exceed a utilization management authorization. Provider Liability
Units were reduced by a utilization management authorization. Provider Liability
Calendar year warning applied
Medical Utilization Edits Applied
CHECK VOID, PARTIAL REFUND. PROVIDER LIABILITY
CHECK VOID, PARTIAL REFUND. PROVIDER LIABILITY
VBB Bypass Explanation #1
SERVICES BILLED ARE NOT ELIGIBLE ACCORDING TO THE PROVIDER AGREEMENT. PROVIDER LIABILITY
June 2014
Page 9
FIRST PRIORITY HEALTH EXPLANATION CODES
X02
X06
X07
X08
X09
X12
X13
X14
X15
X16
X17
X18
X19
X20
X21
X22
X23
X24
X25
X26
X27
X28
X29
X30
X31
X32
X33
X34
X35
X36
X37
X38
X39
X40
X41
X42
X43
X44
X45
X46
X47
X48
X49
X50
X51
X52
X53
X54
X55
X56
X57
X58
X59
X60
X61
X62
X63
X64
X65
Denied non-designated Capitated Provider. Provider Liability
THIS LINE ITEM WAS PREVIOUSLY SUBMITTED AND PROCESSED. PROVIDER LIABILITY
CLAIM PROCESSED WITH INCORRECT MEMBER. PROVIDER LIABILITY
CHECK VOID, FULL REFUND. PROVIDER LIABILITY
THIS CHARGE WAS PREVIOUSLY SUBMITTED AND PROCESSED. PROVIDER LIABILITY
MATERNITY INFORMATION IS REQUIRED. PROVIDER LIABILITY
REFERRAL IS REQUIRED FOR THE SERVICE RENDERED. MEMBER LIABILITY
PLEASE RESUBMIT CLAIM WITH PRIMARY CARRIERS EXPLANATION OF BENEFIT. PROVIDER LIABILITY
SERVICES WERE BILLED ON INCORRECT CLAIM FORM TYPE PLEASE RESUBMIT. PROVIDER LIABILITY
NON-DESIGNATED LAB PROVIDER. PROVIDER LIABILITY
PRE-AUTHORIZATION REQUIREMENTS NOT MET. PROVIDER LIABILITY
ORIGIN/DESTINATION MODIFIERS ARE REQUIRED TO PROCESS CLAIM. PROVIDER LIABILITY
NOTES/MEDICAL RECORDS REQUIRED. SUBMIT WITH NEW CLAIM FORM. PROVIDER LIABILITY
ADDITIONAL INFO REQUIRED TO CONSIDER CHARGES. PROVIDER LIABILITY
REVENUE CODE REQUIRES A CPT/HCPCS CODE. PROVIDER LIABILITY
PAYMENT FOR THESE SERVICES INCLUDED IN PAYMENT OF TRANSPORT. PROVIDER LIABILITY
OTHER INSURANCE IS PRIMARY. RESUBMIT TO APPROPRIATE CARRIER. MEMBER LIABILITY
AUTO RELATED. FORWARD AUTO EXHAUST LETTER/PAYOUT SHEET TO FPH. PROVIDER LIABILITY
CHARGES HAVE BEEN PAID IN FULL BY PRIMARY CARRIER. PROVIDER LIABILITY
EOB FROM PRIMARY CARRIER IS REQUIRED. PLEASE FORWARD TO FPH. PROVIDER LIABILITY
SIGNED SUBROGATION FORM IS REQUIRED FROM THE MEMBER TO COMPLETE PROCESSING. MEMBER LIABILITY
EOB DOES NOT CORRESPOND WITH CHARGES SUBMITTED TO FPH. MEMBER LIABILITY
MEDICARE IS PRIMARY. PLEASE SUBMIT CHARGES TO MEDICARE. MEMBER LIABILITY
PRIMARY INSURANCE PAYMENT IS EQUAL TO OR EXCEEDS FPH ALLOWANCE. PROVIDER LIABILITY
USUAL CUSTOMARY RATE PAID BY PRIMARY INSURANCE. NO FURTHER PAYMENT TO BE MADE BY FPH.
PROVIDER LIABILITY
WORK COMP DOCTOR/FACILITY NOT UTILIZED. MEMBER LIABILITY
AMOUNT ABOVE MEDICARE ALLOWABLE. PROVIDER LIABILITY
PRIMARY INSURANCE DISCOUNT/AMOUNT ABOVE UCR. PROVIDER LIABILITY
RESUBMIT TO PRIMARY INSURANCE WITH INFORMATION THEY REQUIRED. MEMBER LIABILITY
MAJOR MEDICAL EOB IS REQUIRED TO COMPLETE PROCESSING BY FPH. MEMBER LIABILITY
BLACK LUNG EOB IS REQUIRED TO COMPLETE PROCESSING BY FPH. MEMBER LIABILITY
COORDINATION OF BENEFITS QUESTIONNAIRE REQUIRED TO COMPLETE PROCESSING BY FPH. MEMBER
LIABILITY
PAYMENT MADE BY ANOTHER BLUE CROSS PLAN. PROVIDER LIABILITY
PROCEDURE IS NOT ELIG FOR PAYMENT WHEN PERFORMED BY PROV SPEC. PROVIDER LIABILITY
PLEASE RESUBMIT WITH A MORE SPECIFIC DIAGNOSIS CODE. PROVIDER LIABILITY
PROCEDURE PERFORMED AT NON-PAR FACILITY, NO PRE-AUTH EXISTS. MEMBER LIABILITY
THIS PROCEDURE IS NOT SEPARATELY REIMBURSABLE. PROVIDER LIABILITY
READMISSION; $0.00 CONTRACTED RATE HAS BEEN APPLIED. PROVIDER LIABILITY
INVALID PROCEDURE/MODIFIER COMBINATION (PACE). PROVIDER LIABILITY
WORK COMP RELATED. FORWARD CARRIER DENIAL TO FPH. PROVIDER LIABILITY
THE CORRESPONDING HOSPITAL CLAIM IS REQUIRED FOR PROCESSING. PROVIDER LIABILITY
MULTIPLE UNITS REPORTED FOR SAME DATE OF SERVICE. CONTACT CBH DEPT. PROVIDER LIABILITY
SERVICES DENIED BY REGIONAL REFERRAL CENTER. PROVIDER LIABILITY
PROC REPORTED CAN BE PERFORMED ONLY ONCE PER DOS (PACE). PROVIDER LIABILITY
PRE-AUTHORIZATION IS REQUIRED FOR THE SERVICE PROVIDED. PROVIDER LIABILITY
BENEFIT LIMIT EXCEEDED FOR SERVICE RENDERED. MEMBER LIABILITY
TIMELY FILING EXCEEDED FOR SELF-REFERRAL FORM. MEMBER LIABILITY
THE PATIENT’S HEMOCRIT LEVEL & EPO UNITS ADMINISTERED ARE REQUIRED. PROVIDER LIABILITY
SECOND SURG ASSIST/SURGICAL TECH NOT ELIGIBLE FOR PAYMENT. MEMBER NOT RESPONSIBLE FOR
CHARGES. PROVIDER LIABILITY
SERVICES PROVIDED ARE INVALID/INELIGIBLE FOR PROVIDER SPECIFIED. PROVIDER LIABILITY
SERVICES PROV BY A PA ARE NOT ELIGIBLE FOR PAYMENT. PROVIDER LIABILITY
CRNA’S/NURSE ARE NOT ELIGIBLE FOR PAYMENT. PROVIDER LIABILITY
SERVICES DENIED BY MEDICAL DIRECTOR. PROVIDER LIABILITY
SERVICE DENIED BY MEDICAL DIRECTOR. MEMBER LIABILITY
PROCEDURE/DIAGNOSIS DOES NOT MATCH PRE-AUTHORIZATION. PROVIDER LIABILITY
DME CODE/MODIFIER COMBINATION DOES NOT MATCH PRE-AUTHORIZATION. PROVIDER LIABILITY
SERVICES INDICATED ON REFERRAL WERE NOT AUTHORIZED BY PCP. MEMBER LIABILITY
SERVICE INCLUDED AS PART OF IP ALLOWANCE. PROVIDER LIABILITY
MEMBER’S MH/CR BENEFITS ARE CARVED OUT. SUBMIT TO APPROP VENDOR. PROVIDER LIABILITY
June 2014
Page 10
FIRST PRIORITY HEALTH EXPLANATION CODES
X66
X67
X68
X69
X70
X71
X72
X73
X74
X75
X76
X77
X78
X79
X80
X81
X82
X83
X84
X85
X86
X87
X88
X89
X90
X91
X92
X93
X94
X95
X96
X98
XA0
XA1
XA3
XA4
XA5
XA9
XAB
XAD
XAF
XAG
XAI
XAK
XAL
XAM
XAN
XAO
XAP
XAQ
XAR
XAS
XAT
XAU
XAV
XAW
XAX
XAY
XAZ
XB0
XB1
XB2
THESE SERVICES HAVE BEEN FORWARDED TO USBH FOR FURTHER INVESTIGATION. PROVIDER LIABILITY
SERVICES DENIED NOT MEDICALLY NECESSARY. PROVIDER LIABILITY
PLEASE FORWARD CLAIM TO MAGELLAN BEHAVIORAL HEALTH FOR PROCESSING. PROVIDER LIABILITY
MEMBER MUST SELECT A PRIMARY CARE PHYSICIAN. MEMBER LIABILITY
PAYMENT FOR TRANSPORT PD TO FACILITY. PROVIDER LIABILITY
SERVICES NOT AUTHORIZED TO BEGIN UNTIL LATER DATE. MEMBER LIABILITY
SELF-REFERRAL FORM/EOB REQUIRED FOR EACH DATE OF SERVICE. MEMBER LIABILITY
PAYMENT INCLUDED IN PYMT MADE TO FACILITY. PROVIDER LIABILITY
THIS SERVICE IS INHERENT TO PROCEDURE PERFORMED. PROVIDER LIABILITY
PRIOR PRE-AUTH REQUIREMENTS NOT MET. MEMBER LIABILITY
NON-DESIGNATED CAPITATED PROVIDER. PROVIDER LIABILITY
MEMBER’S VISION BENEFIT CARVED OUT. SUBMIT TO APPROPRIATE VENDOR. PROVIDER LIABILITY
SUBMIT TO PA BLUE SHIELD FOR THIS SERVICE. PROVIDER LIABILITY
SUBMITTED THRU BLUECARD IN ERROR. SUBMIT TO LOCAL PLAN. PROVIDER LIABILITY
CLAIM PROCESSED ACCORDING TO USBH. PROVIDER LIABILITY
INVALID NATIONAL DRUG CODE SUBMITTED. PROVIDER LIABILITY
RESUBMIT TO LOCAL BC/BS WITH CORRECT ALPHA PREFIX. PROVIDER LIABILITY
DATE FOR ACCEPTING CLAIMS HAS EXPIRED, PLEASE CONTACT GRP ADMIN. PROVIDER LIABILITY
DELIVERY CHARGE IS REQ TO PROCESS. PROV SHOULD SUBMIT WITH EOB. PROVIDER LIABILITY
THE FIRST VISIT MUST BE USED WITHIN 180 DAYS OF ISSUE DATE. MEMBER LIABILITY
THE BILL TYPE/REV CODE DOESN’T MATCH AUTH. RESUBMIT CORRECTED CLAIM. PROVIDER LIABILITY
UNATTENDED SERVICES ARE INELIGIBLE FOR REIMBURSEMENT. PROVIDER LIABILITY
DATE RANGE BILLED DOESN’T CORRESPOND WITH THE TOTAL UNITS BILLED. PROVIDER LIABILITY
PROCEDURE IS NOT ELIG FOR PAYMENT WHEN PERFORMED BY PROV SPEC. PROVIDER LIABILITY
PROCEDURE BILLED REQUIRES A DATE RANGE. PROVIDER LIABILITY
UNITS BILLED INVALID/EXCESSIVE FOR PROCEDURE BILLED. PROVIDER LIABILITY
INVALID PROCEDURE FOR DELIVERY. RESUBMIT FOR DELIVERY ONLY PROCEDURE. PROVIDER LIABILITY
PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL CASE RATE. PROVIDER LIABILITY
SELF REFERRED TO OUT-OF- NETWORK PROVIDER. MEMBER LIABILITY
PAYMENT REJECTED; FURTHER REVIEW REQUIRED. PROVIDER LIABILITY
PAYMENT IS SUSPENDED, PENDING FURTHER REVIEW. PROVIDER LIABILITY
GLOBAL PAYMENT IS NOT REIMBURSABLE FOR THIS PROCEDURE. PROVIDER LIABILITY
PRE-EXISTING CONDITION NOT ELIGIBLE FOR PAYMENT. MEMBER LIABILITY
PRICE ADJUSTED DUE TO ADDITIONAL LINE ITEM MODIFIERS. PROVIDER LIABILITY
ORIGIN/DESTINATION MODIFIERS ARE REQUIRED TO PROCESS CLAIM. MEMBER LIABILITY
DOCUMENTATION DOES NOT SUPPORT PROCEDURE BILLED. MEMBER LIABILITY
A VALID CPT/HCPCS MODIFIER IS REQUIRED FOR PROCEDURE REPORTED. MEMBER LIABILITY
PRE-EXISTING CONDITION NOT ELIGIBLE FOR PAYMENT. MEMBER LIABILITY
Disallow Assistant Surgeon. Provider Liability
SERVICE IS NOT ELIGIBLE FOR PAYMENT W/E&M VISIT OR J CODE. PROVIDER LIABILITY
PROOF OF PAYMENT REQUIRED FOR REIMBURSEMENT. MEMBER LIABILITY
Claim forwarded to BCNEPA for Processing. Provider Liability
CLAIM SENT TO HIGHMARK BC/BS. PROVIER LIABILITY
THE FIRST OB VISIT DIAGNOSIS IS REQUIRED TO PROCESS CHARGES. PROVIDER LIABILITY
THE SERVICE PROVIDED IS NOT A COVERED BENEFIT. MEMBER LIABILITY
UNSPECIFIED DIAGNOSIS REPORTED. SUBMIT WITH VALID DIAGNOSIS. PROVIDER LIABILITY
SERVICES DENIED NOT MEDICALLY NECESSARY. MEMBER IS RESP FOR CHARGES.
PROVIDER STATUS-MEMBER NOT LIABLE. PROVIDER LIABILITY
THIS SERVICE IS INHERENT TO PROCEDURE PERFORMED. PROVIDER LIABILITY
DIAGNOSIS INVALID FOR POSTPARTUM PROCEDURE REPORTED. PROVIDER LIABILITY
THESE SERVICES HAVE BEEN FORWARDED TO USBH FOR FURTHER INVESTIGATION. PROVIDER LIABILITY
PROCEDURE INVALID WITH DIAGNOSIS REPORTED. PROVIDER LIABILITY
INVALID PLACE OF SERVICE FOR PROCEDURE BILLED. PROVIDER LIABILITY
PRE-ADMISSION TESTING DX REQUIRED FOR PAYMENT. PROVIDER LIABILITY
Date of service billed is greater than the receive date of the claim. Provider Liability
CLAIM REPROCESSED DUE TO PROCESSING/BILLING ERROR. PROVIDER LIABILITY
INVALID PRIMARY ICD PROCEDURE BILLED ON MATERNITY. PROVIDER LIABILITY
PRIVATE ROOM DIFFERENCE NOT COVERED. MEMBER LIABILITY
DAYS BILLED DON’T MATCH APPROVED DAYS. PROVIDER LIABILITY
SCHOOL COUNSELOR IS NOT ELIGIBLE FOR PAYMENT. PROVIDER LIABILITY
ADDITIONAL INFO REQUIRED TO CONSIDER CHARGES. MEMBER LIABILITY
ADDITIONAL INFORMATION REQUIRED TO CONSIDER CHARGES. MEMBER LIABILITY
June 2014
Page 11
FIRST PRIORITY HEALTH EXPLANATION CODES
XB3
XB4
XB5
XB6
XB7
XB8
XB9
XBA
XBB
XBC
XBD
XBF
XBG
XBH
XBI
XBJ
XBK
XBL
XBM
XBN
XBO
XBP
XBQ
XBR
XBS
XBT
XBU
XBV
XBX
XBY
XCA
XCB
XCC
XCD
XCE
XCF
XCG
XCH
XCI
XCJ
XCP
XCQ
XCR
XCS
XCV
XCW
XCX
XCZ
XD0
XD1
XD2
XD3
XD4
XD5
XD6
XD7
XD8
XD9
XDA
XDB
XDC
XDD
ADDITIONAL INFORMATION REQUIRED TO CONSIDER CHARGES. PROVIDER LIABILITY
ADDITIONAL INFORMATION REQUIRED TO CONSIDER CHARGES. PROVIDER LIABILITY
ITS-ADDITIONAL INFORMATION REQUIRED TO CONSIDER CHARGES. MEMBER LIABILITY
TAXONOMY CODE IS MISSING OR INVALID. PROVIDER LIABILITY
COVERAGE OF THIS DME ITEM IS ONLY CONSIDERED WHEN ITEM IS PURCHASED. MEMBER LIABILITY
COVERAGE OF THIS DME ITEM IS ONLY CONSIDERED WHEN THE ITEM IS RENTED. MEMBER LIABILITY
THE MEDICALYL UNLIKELY EDIT VALUE HAS BEEN MET ON A PREVIOUS CLAIM/LIN. PROVIDER LIABILITY
THIS AMOUNT REFLECTS A PRECERT PENALTY. MEMBER IS RESPONSIBLE. MEMBER LIABILITY
RESUBMIT WITH A PROF. SIGNATURE ON THE HCFA 1500 CLAIM FORM. PROVIDER LIABILITY
PER THE CONTROL PLAN, MEMBER IS NOT COVERED. MEMBER LIABILITY
PROVIDER ID/TAX ID IS INVALID OR MISSING. PLEASE RESUBMIT. PROVIDER LIABILITY
THE REVENUE CODE SUBMITTED REQUIRES A CPT/HCPCS CODE. PROVIDER LIABILITY
DUPLICATE TO A CLAIM WHICH WILL BE ADJUDICATED SHORTLY PROVIDER LIABILITY
INVALID PLACE OF SERVICE BILLED. PLEASE RESUBMIT WITH VALID PLACE OF SERVICE. PROVIDER LIABILITY
RESUBMIT A VALID CPT/HCPCS CODE. PROVIDER LIABILITY
DELETED CPT/HCPCS REPORTED. RESUBMIT WITH A VALID CODE. PROVIDER LIABILITY
NO FACILITY LISTED IN FIELD 32. RESUBMIT WITH FACILITY INFORMATION. PROVIDER LIABILITY
ER REVENUE CODE NOT PRESENT ON CLAIM. RESUBMIT WITH APPR REVENUE CODE. PROVIDER LIABILITY
THIS CLAIM HAS BEEN PREVIOUSLY SUBMITTED AND PROCESSED. PROVIDER LIABILITY
NO ASSOCIATED CLAIM ON FILE FOR CHARGES BILLED. PROVIDER LIABILITY
THESE SERVICES ARE INVALID FOR PROVIDER’S SPECIALTY. PROVIDER LIABILITY
DRUG PAID AT PHARMACY, DUPLICATE CHARGES. PROVIDER LIABILITY
ANNUAL INDIVIDUAL COINSURANCE MAXIMUM MET
ANNUAL FAMILY COINSURANCE MAXIMUM MET
ANNUAL SELF-REFERRED INDIVIDUAL COINSURANCE MAXIMUM MET
ANNUAL SELF-REFERRED FAMILY COINSURANCE MAXIMUM MET
SELF-REFERRED LIFETIME INDIVIDUAL BENEFIT EXCEEDED. MEMBER LIABILITY
SELF-REFERRED LIFETIME FAMILY BENEFIT EXCEEDED. MEMBER LIABILITY
LIFETIME INDIVIDUAL OUT OF POCKET MET
LIFETIME FAMILY OUT OF POCKET MET
PROCEDURE IS NOT ELIGIBLE FOR PAYMENT PER PROVIDER CONTRACT. PROVIDER LIABILITY
INVALID FACILITY LISTED IN FIELD 32. RESUBMIT. PROVIDER LIABILITY
THE UNITS BILLED ARE INVALID FOR THE REVENUE CODE BILLED. PROVIDER LIABILITY
MOD REPTD IS DEL/INVALID. PLEASE USE VALID CPT/HCPCS MODS. PROVIDER LIABILITY
RESUBMIT TO LOCAL BC/BS WITH CORRECT ALPHA PREFIX. PROVIDER LIABILITY
LIFETIME IND BENEFIT EXCEEDED. MEMBER LIABILITY
THIS SERVICE WAS BILLED/PROCESSED IN ERROR. MEMBER IS NOT RESPONSIBLE. PROVIDER LIABILITY
SCHEDULE A DISALLOW PROVIDER LIABILITY
PROVIDER ID INCORRECT FOR SERVICES RENDERED. PROVIDER LIABILITY
PHYSICIAN EXTENDER NOT ELIGIBLE FOR PAYMENT UNDER FPH. PROVIDER LIABILITY
SUBMIT TO PENNSYLVANIA BLUE SHIELD FOR THIS SERVICE. PROVIDER LIABILITY
INVALID CODING COMBINATION AS PER CODING GUIDELINES. PROVIDER LIABILITY
A VALID CPT/HCPCS MODIFIER IS REQUIRED FOR PROCEDURE REPORTED. PROVIDER LIABILITY
PROCEDURE PAID IN RATE OR INCLUDED IN ANOTHER SERVICE. PROVIDER LIABILITY
MEMBER NOT ELIGIBLE FOR BENEFITS MEMBER LIABILITY
PAYMENT FOR THIS SERVICE INCLUDED IN PAYMENT OF TRANSPORT PROVIDER LIABILITY
CLAIM CLOSED UNTIL REQUESTED INFORMATION IS RECEIVED FROM SUBSCRIBER. MEMBER LIABILITY
SERVICES PERFORMED IN OFFICE SETTING NOT COVERED FOR THIS PROVIDER. PROVIDER LIABILITY
FILE TO PLAN WHERE ORDERING PHYSICIAN IS LOCATED. PROVIDER LIABILITY
CLM PREV SUBMITTED BY THE PROVIDER OF SERVICE AND PROCESSED. PROVIDER LIABILITY
CLM PREV SUBMITTED BY DPW AND PROCESSED. PROVIDER LIABILITY
CLM PREV SUBMITTED BY THE SUBSCRIBER AND PROCESESED. MEMBER LIABILITY
SERVICE PREV SUBMITTED BY THE PROVIDER OF SERVICE AND PROCESSED. PROVIDER LIABILITY
SERV PREV SUBMITTED BY DPW AND PROCESSED. PROVIDER LIABILITY
CLM PREV SUBMITTED BY SUBSCRIBER AND PROCESSED. MEMBER LIABILITY
PROVIDER BILLING ERROR – NO NPI REPORTED. PROVIDER LIABILITY
FILE LAB SERVICE TO PLAN WHERE THE REFERRING PROVIDER IS LOCATED. PROVIDER LIABILITY
FILE TO PLAN WHERE EQUIPMENT WAS SHIPPED TO OR PURCHASED. PROVIDER LIABILITY
SELF REFERRAL FORM/EOB REQUIRED FOR EACH DATE OF SERVICE. MEMBER LIABILITY
CRNA’S/NURSES ARE NOT ELIGIBLE FOR PAYMENT. PROVIDER LIABILITY
HCFA1500 SUBMITTED WITH INVALID PROVIDER ID. PROVIDER LIABILITY
NO W-9 RECEIVED. CLAIM MAILED BACK TO PROVIDER. PROVIDER LIABILITY
June 2014
Page 12
FIRST PRIORITY HEALTH EXPLANATION CODES
XDF
XDH
XDI
XDJ
XDK
XDL
XDM
XDN
XDO
XDP
XDQ
XDR
XDS
XDT
XDU
XDX
XDY
XDZ
XEA
XEB
XEC
XED
XEE
XEF
XEG
XEH
XEI
XEJ
XEK
XEM
XEN
XEP
XEQ
XER
XES
XEV
XEY
XEZ
XFA
XFB
XFC
XFD
XFE
XFF
XFG
XFH
XFI
XFJ
XFK
XFL
XFM
XFN
XFO
XFP
XFQ
XFR
XFS
XFT
PLEASE RESUBMIT ON A FACILITY ADJUSTMENT FORM. PROVIDER LIABILITY
USUAL CUSTOMARY RATE PAID BY PRIMARY INSURANCE. NO FURTHER PAYMENT TO BE MADE BY FPH.
PROVIDER LIABILITY
THIS AMOUNT REFLECTS A PRECERT PENALTY. MEMBER IS RESPONSIBLE. MEMBER LIABILITY
CLAIM AWAITING RESPONSE FROM HEALTHSCOPE BENEFITS AND WILL BE PROCESSED SHORTLY.
PROVIDER LIABILITY
UNSPECIFIED CODE BILLED WHEN VALID PROCEDURE CODE EXISTS. PLEASE SUBMIT WITH VALID CODE.
PROVIDER LIABILITY
PROCEDURE CODE METHOD NOT REPORTED. PROVIDER LIABILITY
INAPPROPRIATE SETTING FOR SERVICES RENDERED. PROVIDER LIABILITY
A VALID CPT/HCPCS MODIFIER IS REQUIRED FOR PROCEDURE REPORTED. PROVIDER LIABILITY
REQUIRED STATUTORY 120 DAY NOTICE OF WORK COMP INJURY NOT GIVEN TO EMPLOYER. MEMBER LIABILITY
BILL TYPE IS INVALID WITH REVENUE CODE(S) SUBMITTED. PROVIDER LIABILITY
ACCEPTING CLMS FOR THIS GRP HAS EXPIRED. PROV MUST CONTACT HOME PLAN. MEMBER LIABILITY
PROVIDER ON LEAVE OF ABSENCE. CLAIM BILLED IN ERROR. PROVIDER LIABILITY
PATIENT DOES NOT MEET AGE REQUIREMENT FOR PROCEDURE PERFORMED. PROVIDER LIABILITY
CLOSED CLAIM - NO PAYMENT. PROVIDER LIABILITY
USUAL CUSTOMARY RATE PAID BY PRIMARY INSURANCE. NO FURTHER PAYMENT TO BE MADE BY FPH.
PROVIDER LIABILITY
PAYMENT REJECTED - REVIEW IS COMPLETE. PROVIDER LIABILITY
PAYMENT REJECTED - REVIEW IS COMPLETE. PROVIDER LIABILITY
PAYMENT MADE TO FACILITY. PROVIDER LIABILITY
ACCEPTING CLMS FOR GRP HAS EXPIRED. FORWARDED TO GRP TO HANDLE. PROVIDER LIABILITY
TOTAL CHARGES MISSING OR NOT EQUAL TO LINE ITEM CHARGES. PROVIDER LIABILITY
CLAIM REPORCESSED. PER PROVIDER - SERVICE/CLAIM BILLED IN ERROR. PROVIDER LIABILITY
UNITS MISSING OR ZERO REPORTED WITH PROCEDURE/REVENUE CODE BILLED. PROVIDER LIABILITY
UNITS REPORTED DO NOT MATCH DATE RANGE BILLED. PLEASE RESUBMIT. PROVIDER LIABILITY
DATE OF SERVICE/DATE RANGE REPORTED IS INVALID. PLEASE RESUBMIT. PROVIDER LIABILITY
SUBSCRIBER/MEMBER IDENTIFICATION NUMBER IS MISSING OR INVALID. PROVIDER LIABILITY
INVALID PROCEDURE FOR ANESTHESIA SERVICE. PLEASE RESUBMIT. PROVIDER LIABILITY
NDC# IS MISSING/INVALID FOR DRUG REPORTED. PLEASE RESUBMTIT. PROVIDER LIABILITY
BREAK DOWN OF CHARGES IS NEEDED. PLEASE RESUBMIT. PROVIDER LIABILITY
STATEMENT DATE MAY NOT BE LESS THAN STATEMENT FROM DATE. PROVIDER LIABILITY
BILL TYPE IS INVALID WITH REVENUE CODE(S) SUBMITTED. PROVIDER LIABILITY
DELAY IN SERVICE FOR INPATIENT ADMISSION. PROVIDER LIABILITY
GLOBAL PAYMENT IS NOT REIMBURSABLE. PROVIDER LIABILITY
BENEFIT IS LIMITED TO SPINAL MANIPULATION/OFF. VISIT MAY BE REDUNDANT. PROVIDER LIABILITY
MEMBER NOT ELIGIBLE FOR BENEFITS. MEMBER LIABILITY
SERVICES PERFORMED IN OFFICE SETTING NOT COVERED FOR THIS PROVIDER. PROVIDER LIABILITY
PROCEDURE ONLY PAYABLE WITH OWNED STATIONARY EQUIPMENT. PROVIDER LIABILITY
CLAIM PROCESSED WITH INCORRECT MEMBER. PROVIDER LIABILITY
MATERNITY INFORMATION IS REQUIRED. PROVIDER LIABILITY
NOTES/MEDICAL RECORDS REQUIRED. SUBMIT WITH NEW CLAIM FORM. PROVIDER LIABILITY
AUTO RELATED. FORWARD AUTO EXHAUST LETTER. PROVIDER LIABILITY
CHARGES HAVE BEEN PAID IN FULL BY PRIMARY CARRIER. PROVIDER LIABILITY
EOB FROM PRIMARY CARRIER IS REQUIRED. PLEASE FORWARD TO FPH. PROVIDER LIABILITY
MAJOR MEDICAL EOB IS REQUIRED TO COMPLETE PROCESSING BY FPH. MEMBER LIABILITY
WORK COMP RELATED. FORWARD CARRIER DENIAL TO FPH. PROVIDER LIABILITY
PRE-AUTHORIZATION IS REQUIRED FOR THE SERVICE PROVIDED. PROVIDER LIABILITY
MEMBER MUST SELECT A PRIMARY CARE PROVIDER. MEMBER LIABILITY
SELF REFERRAL FORM/EOB REQUIRED FOR EACH DATE OF SERVICE. MEMBER LIABILITY
THE BILL TYPE/REV CODE DOESN’T MATCH AUTH. RESUBMIT CORRECTED CLAIM. PROVIDER LIABILITY
INVALID PRIMARY ICD PROCEDURE BILLED ON MATERNITY. PROVIDER LIABILITY
PROVIDER ID/TAX ID IS INVALID OR MISSING. PLEASE RESUBMIT. PROVIDER LIABILITY
NO FACILITY LISTED IN FIELD 32. RESUBMIT WITH FACILITY INFORMATION. PROVIDER LIABILITY
RESUBMIT TO LOCAL BC/BS WITH CORRECT ALPHA PREFIX. PROVIDER LIABILITY
CLOSE CLAIM – NO PAYMENT. PROVIDER LIABILITY
SUBSCRIBER/MEMBER IDENTIFICATION NUMBER IS MISSING OR INVALID. PROVIDER LIABILITY
BILL TYPE IS INVALID WITH REVENUE CODE(S) SUBMITTED. PROVIDER LIABILITY
CLAIM PROCESSED UNDER INCORRECT GROUP PROVIDER LIABILITY
RENT TO PURCHASE MET. NO FURTHER PAYMENT TO BE MADE BY FPH. PROVIDER LIABILITY
DATE OF SERVICE/DATE RANGE REPORTED IS INVALID. PLEASE RESUBMIT. PROVIDER LIABILITY
June 2014
Page 13
FIRST PRIORITY HEALTH EXPLANATION CODES
XFU
XFV
XFW
XFX
XFY
XFZ
XGA
XGB
XGC
XGD
XGE
XGF
XGH
XGI
XGJ
XGK
XGL
XGM
XGN
XGO
XGQ
XGR
XGS
XGT
XGU
XGV
XGW
XGX
XGY
XGZ
XHA
XHB
XHC
XHD
XHE
XHF
XHG
XHH
XHI
XHJ
XHK
XHL
XHM
XHN
XHO
XHP
XHQ
XHR
XHS
XHT
XHU
XIA
XIB
XIC
XID
XIE
XIF
XIG
XIH
XII
XIJ
XIK
WORK COMP DOCTOR/FACILITY NOT UTILIZED. MEMBER LIABILITY
PRIMARY INSURANCE PAYMENT IS EQUAL TO OR EXCEEDS FPH ALLOWANCE. PROVIDER LIABILITY
EOB DOES NOT CORRESPOND WITH CHARGES SUBMITTED TO FPH. MEMBER LIABILITY
REQUIRED STATUTORY 120 DAY NOTICE OF WORK COMP INJURY NOT GIVEN TO EMP. MEMBER LIABILITY
MEMBER RECEIVED WORK COMP SETTLEMENT. MEMBER RESPONSIBLE FOR PAYMENT.
MEMBER RECEIVED WORK COMP SETTLEMENT. MEMBER RESPONSIBLE FOR PAYMENT.
HIGH DOLLAR CLAIM - REVIEWED AND REJECTED. PROVIDER LIABILITY
SECOND READING OF MRI/RADIOLOGY STUDIES ARE NOT ELIGIBLE FOR PAYMENT. PROVIDER LIABILITY
RENT TO PURCHASE MET. NO FURTHER PAYMENT TO BE MADE BY FPH. PROVIDER LIABILITY
THIS PROCEDURE IS NOT SEPARATELY REIMBURSEABLE. PROVIDER LIABILITY
THIS SERVICE WAS BILLED/PROCESSED IN ERROR. MEMB IS NOT RESPONSIBLE. PROVIDER LIABILITY
MEDICARE IS PRIMARY. PLEASE SUMBIT CHARGES TO MEDICARE. PROVIDER LIABILITY
THIS SERVICE WAS BILLED/PROCEESSED IN ERROR. MEMB IS NOT RESPONSIBLE. PROVIDER LIABILITY
HOSPITALIST SERVICE PAID UNDER ARRANGEMENT. PROVIDER LIABILITY
EOB IS ILLEGIBLE. PROVIDER LIABILITY
PRIOR AUTH NOT OBTAINED. MEMBER IS NOT RESPONSIBLE FOR CHARGES. PROVIDER LIABILITY
PRIOR AUTH NOT OBTAINED. MEMBER IS NOT RESPONSIBLE FOR CHARGES. PROVIDER LIABILITY
PRIOR AUTH REQUIRED FOR THIS SERVICE. MEMBER IS RESPONSIBLE FOR CHARGES. MEMBER LIABILITY
PRIOR AUTH IS REQUIRED FOR SERVICE. MEMBER IS RESPONSIBLE FOR CHARGES. MEMBER LIABILITY
SELF REFERRAL FORM/EOB REQUIRED FOR EACH DATE OF SERVICE. MEMBER LIABILITY
SERVICE AVAILABLE IN NETWORK. MEMBER RESPONSIBLE FOR CHARGES. MEMBER LIABILITY
TAXONOMY CODE DOES NOT MATCH SYSTEM. PROVIDER LIABILITY
INVOICE IS REQUIRED FOR PAYMENT. PROVIDER LIABILITY
GROUP NOT PAID TO DATE FOR SERVICE DATE. PROVIDER LIABILITY
THIS CLAIM HAS BEEN PREVIOUSLY SUBMITTED AND PROCESSED. PROVIDER LIABILITY
PRIOR AUTH NOT OBTAINED. MEMBER IS NOT RESPONSIBLE FOR CHARGES. PROVIDER LIABILITY
PRIOR AUTH REQUIRED FOR THIS SERVICE. MEMBER RESPONSIBLE FOR CHARGES.
CLAIM REPROCESSED PAID TO INCORRECT PROVIDER. PROVIDER LIABILITY
REPROCESSED PROV BILLING ERROR. PROVIDER LIABILITY
THIS CLAIM IS A DUPLICATE TO A PREVIOUSLY SUBMITTED GHI CLAIM. PROVIDER LIABILITY
PRIMARY CARRIER PAYMENT INFO RECD. EOB NEEDED FROM SECONDARY CARRIER. PROVIDER LIABILITY
SERVICE AVAILABLE IN NETWORK. MEMBER RESPONSIBLE FOR CHARGES. MEMBER LIABILITY
PRIOR PAYER FINALIZATION REQUIRED. MEMBER LIABILITY
PRIOR PAYER FINALIZATION REQUIRED. MEMBER LIABILITY
NEED CORRESPONDING APPROVED PROFESSIONAL CLAIM. PROVIDER LIABILITY
SERVICES DENIED/DONE BY A NONPAR PROVIDER. MEMBER LIABILITY
PROVIDER BILLING ERROR. WRONG NPI REPORTED. PROVIDER LIABILITY
BILLING ERROR. SPECIFIC CODE SHOULD BE USED FOR SERVICE BILLED. PROVIDER LIABILITY
A VALID CPT/HCPCS IS REQUIRED FOR PROCESSING. PROVIDER LIABILITY
PROVIDER NEEDS TO SUBMIT A CONCURRENT REVIEW FORM FOR ADDITIONAL UNITS. PROVIDER LIABILITY
SUBSCRIBER TERMINATED NOT ELIGIBLE FOR BENEFITS. MEMBER LIABILITY
SUBSCRIBER TERMINATED NOT ELIGIBLE FOR BENEFITS. MEMBER LIABILITY
PRIOR AUTH DENIED FOR DISALLOW RETROSPECTIVE REQUEST. PROVIDER LIABILITY
PROV LEGACY # NOT REPORTED IN FIELD 19, THIS # IS REQUIRED. PROVIDER LIABILITY
PROVIDER LEGACY # NOT REPORTED IN FIELD 57, THIS # IS REQUIRED. PROVIDER LIABILITY
H1N1 VACCINE PROVIDED AT NO COST BY THE FEDERAL GOVERNMENT. PROVIDER LIABILITY
ADJUSTMENT DENIED
SUBMIT TO HIGHMARK BLUE CROSS BLUE SHIELD. PROVIDER LIABILITY
PAYMENT WILL BE INCLUDED IN GLOBAL CASE RATE FOR TRANSPLANT. PROVIDER LIABILITY
PAYMENT WILL BE INCLUDED IN GLOBAL CASE RATE FOR TRANSPLANT. PROVIDER LIABILITY
INCORRECT PAYMENT DISPOSITION CODE RECEIVED. PROVIDER LIABILITY
AUTO RELATED. FORWARD AUTO EXHAUST LETTER/PAYOUT SHEET TO FPH. MEMBER LIABILITY
DUPLICATE TO A CLAIM WHICH WILL BE ADJUDICATED SHORTLY. PROVIDER LIABILITY
PLEASE RESUBMIT ON A FACILITY ADJUSTMENT FORM. PROVIDER LIABILITY
NOTES/MEDICAL RECORDS REQUIRED. MEMBER LIABILITY
NOTES/MEDICAL RECORDS REQUIRED. MEMBER LIABILITY
DAYS BILLED DON’T MATCH APPROVED DAYS. MEMBER LIABILITY
PROCEDURE CODES BILLED DO NOT MATCH PRE-AUTH CODES. MEMBER LIABILITY
NOT COVERED AS MEDICAL. PLEASE HAVE PROVIDER SUBMIT TO PHARMACY CARRIER. MEMBER LIABILITY
UNABLE TO DETERMINE THE UNLISTED SERVICE BILLED – CONTACT PROVIDER. MEMBER LIABILITY
WORK COMP RELATED. FORWARD CARRIER DENIAL TO FPH. MEMBER LIABILITY
WORK COMP RELATED. FORWARD CARRIER DENIAL. MEMBER LIABILITY
June 2014
Page 14
FIRST PRIORITY HEALTH EXPLANATION CODES
XIL
XIM
XIN
XIO
XIP
XIQ
XIR
XIS
XIT
XJ1
XJ2
XJ3
XJ4
XJ5
XPG
XPH
XPI
XPJ
XPK
XPL
XPM
XPN
XPO
XPP
XPQ
XPR
XPS
XPT
XPU
XPV
XPW
XPY
XPZ
XQ1
XQ2
XQ3
XQ4
XQ5
XQ6
XSU
Z01
Z02
Z03
Z04
Z06
Z07
Z08
Z09
Z10
Z11
Z12
Z13
Z14
Z15
Z16
Z17
Z18
Z19
Z20
Z21
Z22
Z23
CHARGES HAVE BEEN PAID IN FULL BY PRIMARY CARRIER. MEMBER LIABILITY
CHARGES HAVE BEEN PAID IN FULL BY PRIMARY CARRIER. MEMBER LIABILITY
INCORRECT PROVIDER ID REPORTED IN FIELD 19. PLEASE RESUBMIT. PROVIDER LIABILITY
PRIMARY INSURANCE PAYMENT IS EQUAL TO OR EXCEEDS FPH ALLOWANCE. MEMBER LIABILITY
PROCEDURE CODE IS INCONSISTENT WITH PATIENT’S AGE. MEMBER LIABILITY
DESCRIPTION OF SERVICES RENDERED NEEDED BEFORE CLAIM CAN BE CONSIDERED. MEMBER LIABILITY
MEDICAL RECORDS HAVE BEEN REQUESTED AND PENDING INTERNAL REVIEW. MEMBER LIABILITY
MEDICAL RECORDS HAVE BEEN REQUESTED AND PENDING INTERNAL REVIEW. MEMBER LIABILITY
DESCRIPTION OF SERVICES RENDERED NEEDED BEFORE CLAIM CAN BE CONSIDERED. MEMBER LIABILITY
SERVICES ARE NOT COVERED BY MEDICARE. SUBMIT TO LOCAL BLUE CROSS. PROVIDER LIABILITY
MEDICARE BENEFITS EXHAUSTED. SUBMIT TO LOCAL BLUE CROSS. PROVIDER LIABILITY
AMOUNT DISALLOWED HAS BEEN DETERMINED TO BE NOT MEDICALLY NECESSARY. MEMBER LIABILITY
PAYMENT WILL BE INCLUDED IN GLOBAL CASE RATE FOR TRANSPLANT. MEMBER LIABILITY
INVALID TYPE OF BILL. PROVIDER LIABILITY.
SUBMITTED THRU BLUECARD IN ERROR. SUBMIT TO LOCAL PLAN. PROVIDER LIABILITY
NOT A COVERED SERVICE MEMBER LIABILITY
BENEFITS ARE EXHAUSTED. MEMBER LIABILITY
THIS CLAIM HAS BEEN PREVIOUSLY SUBMITTED AND PROCESSED. MEMBER LIABILITY
THIS LINE ITEM WAS PREVIOUSLY SUBMITTED AND PROCESSED. MEMBER LIABILITY
HIGH DOLLAR CLIAM – REVIEWED AND REJECTED. MEMBER LIABILITY
EOB FROM PRIMARY CARRIER IS REQUIRED. PLEASE FORWARD TO FPH. MEMBER LIABILITY
EOB FROM PRIMARY CARRIER IS REQUIRED. PLEASE FORWARD TO FPH. MEMBER LIABILITY
PAYMENT REJECTED. FURTHER REVIEW REQUIRED.
PAYMENT REJECTED. REVIEW IS COMPLETE
MEDICARE PQRI CODE. PHYSICIAN SHOULD NOT CHARGE FOR THESE CODES.
HCR WOMENS PREVENTIVE
CLAIM TO BE FILED TO PLAN IN WHOSE SERVICE AREA THE SPECIMEN WAS DRAWN. MEMBER LIABILITY
CLAIM TO BE FILED TO PLAN’S SERVICE AREA DME WAS SHIPPED TO/PURCHASED. MEMBER LIABILITY
SPEC PHARMACY CLAIM-FILE TO PLAN’S SERVICE AREA OF ORDERING PHYSICIANS LOCATED. MEMBER LIABILITY
INVALID TYPE OF BILL. PROVIDER LIABILITY.
SERVICE IS COVERED UNDER CAPITATION. PROVIDER ALREADY RECEIVED PAYMENT.
CAP LAB SERVICES WERE BILLED ON INCORRECT CLAIM FORM TYPE. RESUBMIT. PROVIDER LIABILITY
CAP LAB SERVICES WERE BILLED ON INCORRECT CLAIM FORM TYPE. RESUBMIT. PROVIDER LIABILITY
CLAIM FORWARDED TO LOCAL PLAN FOR PROCESSING. PROVIDER LIABILITY
SERVICES WERE FORWARDED TO LOCAL PLAN FOR PROCESSING. PROVIDER LIABILITY
A COPY OF ALL DIAGNOSTIC REPORTS FOR THE PATIENT IS NEEDED. MEMBER LIABILITY
A COPY OF PET/MRI/CT SCAN REPORT/RESULTS IS NEEDED. MEMBER LIABILITY
A COPY OF THE EEG REPORT WITH ANALYSIS IS NEEDED. MEMBER LIABILITY
THE ICD CODE VERSION SUBMITTED BY PROVIDER NOT COMPLIANT. PROVIDER LIABILITY
SUBRO CHECK RECEIVED INTERNAL ADJUSTMENT ONLY
CO-INSURANCE AMOUNT APPLIED PER CONTROL PLAN. MEMBER LIABILITY
CO-PAYMENT AMOUNT APPLIED PER CONTROL PLAN. MEMBER LIABILITY
DEDUCTIBLE AMOUNT APPLIED PER CONTROL PLAN. MEMBER LIABILITY
DENIED DUPLICATE PER THE CONTROL PLAN. PROVIDER LIABILITY
EXTERNAL PRICING APPROVED. PROVIDER LIABILITY
EXTERNAL PRICING DISALLOW. PROVIDER LIABILITY
DATE FOR ACCEPTING CALIMS HAS EXPIRED. PLEASE CONTACT GRP ADMIN. PROVIDER LIABILITY
DATE FOR ACCEPTING CLAIMS HAS EXPIRED. PLEASE CONTACT GROUP ADMIN. MEMBER LIABILITY
DATE FOR ACDEPTING CLAIMS HAS EXPIRED. PLEASE CONTACT GROUP ADMIN. MEMBER LIABILITY
DENIED FOR CERTIFICATE LETTER OF MEDICAL NECESSITY. MEMBER LIABILITY
DENIED FOR SPECIFIC REQUESTED MEDICAL INFORMATION. MEMBER LIABILITY
EMERGENCY SERVICES RECORDS NEEDED FOR FINAL BENEFIT DETERMINATION. MEMBER LIABILITY
DENIED UNTIL SUBSTANCE ABUSE RECORDS ARE RECEIVED. MEMBER LIABILITY
ACCIDENT DATE &/OR ONSET DATE NEEDED FOR FINAL BENEFIT DETERMINATION. MEMBER LIABILITY
DENIED FOR PSYCHIATRIC PROGRESS NOTES OR PSYCHIATRIC TEAM CONF NOTES. MEMBER LIABILITY
PROGRESS NOTES/REPORT NEEDED FOR FINAL BENEFIT DETERMINATION. MEMBER LIABILITY
DISCHARGE SUMMARY NEEDED FOR FINAL BENEFIT DETERMINATION. MEMBER LIABILITY
DENIED UNTIL WE RECEIVE THE RESULTS OF PSYCHIATRIC TESTING. MEMBER LIABILITY
LAB REPORT NEEDED BEFORE CLAIM CAN BE PROCESSED. MEMBER LIABILITY
DENIED UNTIL WE RECEIVE PSYCHIATRIC ASSESSMENT/EVALUATION. MEMBER LIABILITY
DENIED UNTIL WE RECEIVE ENTIRE PSYCHIATRIC RECORD. MEMBER LIABILITY
OPERATIVE/SURGERY REPORT NEEDED FOR FINAL BENEFIT DETERMINATION. MEMBER LIABILITY
June 2014
Page 15
FIRST PRIORITY HEALTH EXPLANATION CODES
Z24
Z25
Z26
Z27
Z28
Z29
Z30
Z31
Z32
Z33
Z34
Z35
Z36
Z37
Z38
Z39
Z40
Z41
Z42
Z43
Z44
Z45
Z46
Z47
DENIED UNTIL WE RECEIVE X-RAYS/PHOTOS. MEMBER LIABILITY
DENIED UNTIL WE RECEIVE COMPLETE MEDICAL RECORDS. MEMBER LIABILITY
DENIED UNTIL PREVIOUSLY REQUESTED MEDICAL RECORDS RECEIVED. MEMBER LIABILITY
PATHOLOGY REPORT NEEDED FOR FINAL BENEFIT DETERMINATION. MEMBER LIABILITY
DENIED FOR THE FIRST CONSULTATION DATE ABOUT THIS CONDITION. MEMBER LIABILITY
RADIOLOGY REPORT NEEDED FOR FINAL BENEFIT DETERMINATION. MEMBER LIABILITY
TREATMENT PLAN NEEDED FOR FINAL BENEFIT DETERMINATION. MEMBER LIABILITY
DENIED UNTIL WE RECEIVE A COPY OF THE DELIVERY REPORT. MEMBER LIABILITY
DENIED UNTIL WE RECEIVE A COPY OF THE VEIN STUDY REPORT. MEMBER LIABILITY
MEDICAL HISTORY INFORMATION REQUESTED FROM ANOTHER PROVIDER NEEDED. MEMBER LIABILITY
DENIED UNTIL WE RECEIVE A COPY OF SLEEP STUDY REPORT. MEMBER LIABILITY
SIGNED RELEASE OF INFO & MEDICAL RECORDS NEEDED FOR CHARGES TO BE CONSIDERED. MEMBER LIABILITY
DENIED FOR MANUFACTURER’S DESCRIPTION OF THIS SUPPLY/EQUIPMENT. MEMBER LIABILITY
COPY OF AMBULANCE REPORT NEEDED FOR CLAIM TO BE RECONSIDERED. MEMBER LIABILITY
COPY OF ANESTHESIA REPORT NEEDED TO RECONSIDER CLAIM. MEMBER LIABILITY
MAX VISITS FOR PHYSICAL THERAPY REACHED. NOTES ARE NEEDED. MEMBER LIABILITY
MAX VISITS FOR SPEECH THERAPY REACHED. NOTES ARE NEEDED. MEMBER LIAIBLITY
PHYS RECORDS, PATIENT’S HISTORY & PHYS &/OR PLAN OF TREATMENT NEEDED. MEMBER LIABILITY
DENIED UNTIL WE RECEIVE THE HEIGHT, WEIGHT, AND FRAME OF THE PATIENT. MEMBER LIABILITY
A COPY OF THE CURRENT BLOOD GASES REPORT IS NEEDED TO RECONSIDER CLAIM. MEMBER LIABILITY
DENIED FOR THE NAME, DOSAGE, QUANTITY AND RELATED NDC NUMBER OF THE DRUG. MEMBER LIABILITY
INFORMATION ON ORDERING/REFERRING PHYSICIAN IS NEEDED TO RECONSIDER THE CLAIM. MEMBER LIABILITY
DENIED FOR A COPY OF PSYCHIATRIC EVALUATION ALONG WITH THE SESSION LENGTH. MEMBER LIABILITY
ORIGIN/DESTINATION MODIFIERS ARE REQUIRED TO PROCESS CLAIM. MEMBER LIABILITY
June 2014
Page 16

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