28
Claim Adjustment Reason Codes-Texas (cont.)
160 NOT COVERED OBESITY
Services related to the treatment of obesity are not covered under this plan.
161 NOT COVERED RADIAL KERATOTOMY
Radial Keratotomy is not a covered service under this plan.
162 NOT COVERED LOW VISION AID/SVC
Services and equipment related to low vision aids are not covered services under this plan.
164 NOT COVERED ROUTINE CHIROPRACT
Routine chiropractic services are not covered services under this plan.
165 NOT COVERED ER FOR ROUTINE SVC
Emergency services are services needed immediately due to sudden illness or injury. Since the
services received do not meet these requirements, the services are not covered under the Plan.
166 NOT COVERED HEALTH EDUCATION
Health Education services are not covered services under this plan.
167 NOT MEDICALLY NECESSARY
The service requested was reviewed by our Medical Director. The Medical documentation received
does not support the need for this service.
168 PAID AT DRG RATE
This claim was paid at the DRG rate.
171 NOT COVERED BLOOD FIRST 3 UNIT
The first three units of blood are not covered services under this plan.
174 DUPLICATE OF CLAIM IN REVIEW
This claim is a duplicate of a claim that is currently in process.
175 PREVIOUSLY DENIED
This claim has been denied. Please review your records and contact our Provider Service Team for
assistance.
176 SUBMITTED W/O ADA CODE
Please resubmit this claim with American Dental Association Codes.
177 MULTIPLE SURGERY DEDUCTION
Standard multiple surgery rules have been applied to this service.
180 INAPPROPRIATE MODIFIER
This modifier is not appropriate for this procedure code. Please resubmit this claim with appropriate
codes.
181 MULT PROC BILLED W/O MODIFIER
Please resubmit with this claim with appropriate modifiers.
186
PREVIOUSLY APPLIED TO
DEDUCTIBLE
The approved amount for this service was previously applied to the Member's deductible.
193 PREVIOUSLY APPLIED TO COPAYMENT
The approved amount for this service was previously applied to the Member's co-payment.
200 INCLUDED IN DRG RATE
Payment for this service is included in the DRG rate.
204 PAID AT CASE RATE
Reimbursement for this claim is made at the case rate.
205 INCLUDED IN CASE RATE
Payment for this service is included in the case rate.
206 INCLUDED IN ASC RATE
Payment for this service is included in the ASC rate.
216
SUBMIT CLAIM TO MENTAL HEALTH
VENDOR
Please submit this claim to the Behavioral Health Vendor.
217 INVALID NDC NUMBER
Please resubmit with a valid National Drug Code (NDC) number. The number submitted is not valid.
221 PD AT STOPLOSS RATE
This claim was reimbursed according to the contracted stop-loss rate.
222 INCLUDED IN STOPLOSS RATE
Reimbursement for this service is included in the contracted stop-loss rate.
223 SUBMIT CLAIM WITH INVOICE
Please resubmit this claim with the appropriate invoice.
224 OVERTURNED APPEAL
This claim represents a change to a prior claim based on an appeal decision.
230 CUSTOMER SERVICE AUTH ISSUE
This claim was reprocessed as the result of a customer service case.
231 SUBMIT WITH CORRECT POS
Please resubmit this claim with a corrected place of service.
233 CUSTOMER SERVICE CLAIMS ISSUE
This claim was reprocessed as the result of a customer service case.
234 RETRO REVIEW IN PROCESS
Our Health Services Department has requested Medical Records on this admission. When the
decision has been rendered, the claim will be processed in accordance with the decision.
