29
Claim Adjustment Reason Codes-Texas (cont.)
251 DN TO OBSERVATION RATE
This claim is processed as an observation stay.
252 RESUBMIT AS OBSERVATION
This stay was authorized as observation. Please resubmit this claims as an observation claim
255 IACD SERVICES - BILL MEDICARE
This claim is the responsibility of Original Medicare. Please bill this claim directly to Medicare with
the appropriate codes.
256 REBILL WITH CPT CODES
Please resubmit this claim with CPT4 codes.
267 PRIMARY CARRIER PAYMENT
This amount represents the payment made by the primary carrier.
268 EOB REQUESTED
Please resubmit with an Explanation of Benefits from the primary insurance carrier.
270 INCORRECT BILL TYPE
Please resubmit with a corrected Bill Type.
275 MISSING DRG
Please resubmit this claim with the appropriate DRG code.
279 QUARTERLY MAXIMUM REACHED
The quarterly dental maximum has been met. No additional dental benefits are available for this
quarter.
281 NON QUEST LAB PROVIDER
Laboratory services must be provided by Quest Laboratory unless the services have been pre
authorized.
288 ITEMIZED BILL NOT= TO CHARGES
Please resubmit a corrected claim. The total on the itemized bill does not equal the total of the billed
charges for these items.
302 UNLISTED PROCEDURE
Please resubmit this claim with medical records to support the unlisted procedure code.
305 DN GRADED TO SKILLED NURSING
This claim is processed as a skilled nursing claim.
306 DN GRADED TO TELEMETRY
This claim is processed as a telemetry stay.
308 NEED VALID ANESTHESIA CODE
Anesthesia claims must be submitted with ASA codes. Please resubmit this claim with ASA codes.
310 DN GRADED TO MED/SURG DAY
This claim is processed as a medical/surgical stay.
311 DN GRADED TO SUBACUTE
This claim is processed as a sub-acute stay.
312 INCLUDED IN INPATIENT PER DIEM
Reimbursement for this service is included in the inpatient per diem payment.
402
TRANSPORTATION MAXIMUM
REACHED
The maximum benefit of 12 routine transportation roundtrips to plan-approved locations for covered
health care services has been provided and no additional benefits are available.
404 MEDICAL NUTRITION THERAPY
Medical nutrition therapy must be approved in advance of the therapy.
405 SMOKING CESSATION PROGRAM
Smoking cessation counseling programs require prior authorization.
450 GLASSES ONE PAIR EVERY 2 YEARS
One pair of eye glasses is a covered benefit every two years. This pair of glasses exceeds the benefit
maximum.
451 HEARING AID MAXIMUM REACHED
The maximum benefit for hearing aids has been provided and no additional benefits are available.
452 ROUTINE PODIATRY MAX REACHED
The maximum benefit for routine podiatry services of 4 visits every calendar year has been reached
and no additional benefits are available.
505 BILL WITH SPECIFIC DATES
Please resubmit this claim with specific dates of service.
560 INCORRECT NUMBER OF UNITS
Please submit with the correct number of units.
574 UNIT COST < $1,000
The item billed is less than $1,000 and no separate reimbursement is due.
612 INCORRECT DISCHARGE DATE
This claim was submitted with an incorrect discharge date. Please resubmit with a correct date.
615 DRG GROUPER DISCREPANCY
The DRG listed on the claim does not match the DRG derived from the claim. Please resubmit with
correct information.
