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Claim Adjustment Reason Codes-Texas (cont.)
104 PAID AT PER DIEM RATE
The payment for this service is included in the per diem rate.
105 PREVIOUSLY PAID
This claim has been previously processed. Please review your records and contact our Provider
Service Team for assistance.
109 SUBMITTED W/O SERVICE UNITS
Please resubmit this claim with the units field completed.
110 MILEAGE INCLUDED IN BASE RATE
The mileage is included in the base rate and is not separately reimbursable.
114 POST DATES AUTHORIZATION DATES
This service was rendered after the expiration date of the authorization.
118 UR DENIED HOSPITAL DAYS
These hospital days have been denied by our Health Services Department.
120 PATIENT CONVENIENCE ITEM
Patient convenience items are not covered under this benefit plan.
123 DENTAL COPAY/PATIENT LIABILITY
This is a Member co-payment amount.
124 EXCEEDS AUTHORIZATION
This service exceeds the number of services authorized.
127 NOT ELIG ON DATE OF SERVICE
This patient was not a Bravo Health Member on the date of service.
128 SUBMIT TO SENIOR PARTNERS
Please resubmit this claim to Senior Partners because the service date is within their coverage period.
130 PROVIDE DETAIL SERVICE DATES
Please resubmit this claim with a detailed bill showing each separate date of service.
132 AUTH FOR DIFFERENT PROVIDER
The authorization on file for this service was issued to a different Provider.
134 ER VISIT W/IN 72 HRS OF ADMIT
Emergency Room visits within 72 hours of an inpatient admission cannot be billed and reimbursed
separately.
135 ITEMIZED BILL REQUESTED
Please resubmit with an itemized bill.
136 SUBMITTED W/O MODIFIER
Please resubmit with appropriate modifier(s)
137 SUBMIT WITH NDC NUMBERS
Please resubmit with National Drug Code (NDC) numbers.
139 NO CHARGE BILLED
Please resubmit with billed charges for each service.
140 NOT COVERED SELF ADMIN RX
Self administered drugs are not covered services under this plan.
141 NOT COVERED EXPERIMENTAL
Experimental treatments are not covered services under this plan.
142 NOT COVERED ACUPUNCTURE
Acupuncture is not a covered service under this plan.
143 NOT COVERED COSMETIC
Cosmetic services are not covered services under this plan.
144 NOT COVERED CUSTODIAL CARE
Custodial services are not covered services under this plan.
145 NOT COVERED HOMEMAKER SVC
Homemaker services are not covered services under this plan.
147 NOT COVERED DELIVERED MEAL
Delivered meals are not covered services under this plan.
148 NOT COVERED NATUROPATH SVC
Naturopath services are not covered services under this plan.
149 NOT COVERED FULL TIME NURSING
Full time nursing services are not covered services under this plan.
150 NOT COVERED ORTHOPEDIC SHOES
Orthopedic shoes are not covered items under this plan.
151 NOT COVERED FOOT SUPPORT
Foot supports are not covered items under this plan.
153 NOT COVERED PRIVATE DUTY NURSE
Private Duty Nursing is not a covered service under this plan.
154 NOT COVERED PRIVATE ROOM
Private Room charges are not covered under this plan.
155 NOT COVERED CHARGE BY RELATIVE
Services rendered by a patient's relative are not covered services under this plan.
157 NOT COVERED SEX CHANGE
Services related to a sex change are not covered services under this plan.
158 NOT COVERED STERILIZ. REVERSAL
Services related to sterilization reversal are not covered services under this plan.
159 NOT COVERED NON RX CONTRACEPT
Non prescription contraceptives are not covered under this plan.
