Below are the most common rejections billers receive from the insurance companies. If you do not see a rejection you are looking for listed below, please contact Support.
Note: For more information on what the denials mean, contact the insurance company directly for details.
Related Articles and links:
Claim Adjustment Reason Codes
- 197 - Precertification/Authorization/Notification/Pretreatment absent.
- 204 - Service/equipment/drug is not covered under the patient's current benefit plan.
- 96 - Non covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
- 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing.
- 182 - Procedure modifier was invalid on the date of service.
- 45 - Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. Generally you received payment and the payer is simply telling you what portion of the bill was not allowed according to your insurance contract.
- 109 - Claim/service not covered by this payer/contractor. Tells that you might have a coordination of benefits issues that needs to be resolved. You must send the claim/service to the correct payer/contractor.
- 16 - Claim/ service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
NOT RECOVERABLE
- 200 - Expenses incurred during lapse in coverage.
- 26 - Expenses incurred prior to coverage.
- 27 - Expenses incurred after coverage terminated.
- 47 - This (these) diagnosis(es) is (are) not covered, missing or invalid.
Additional Non Recoverable Codes
- PR - Patient Responsibility Adjustments.
- PR 1 - Deductible - the amount you pay out of pocket.
- PR 2 - Coinsurance once the annual deductible is reached, the insurance company will begin to pay a portion of all covered costs.
- PR 3 - Co-payment some insurance plans do not have deductibles or coinsurance at all, and instead charge a co-pay fee for any office visit.