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Claim Adjustment Reason Codes-Texas (cont.)
619 SUBMIT OPERATIVE NOTES
Please resubmit this claim with operative notes.
620 SUBMIT TO DAVIS VISION
Please submit this claim to Davis Vision.
620 SUBMIT TO DAVIS VISION
Please submit this claim to Davis Vision.
621 CONVERTED TO ASA CODE
The procedure code for this service was converted to an ASA code for pricing. Please submit all future
claims with ASA codes.
624 NDC # DOES NOT MATCH RX NAME
This NDC number submitted with this claim is not valid for the drug name listed on the claim. Please
resubmit with the correct code and name.
702 REBILL USING MEDICARE G CODES
Please resubmit with the appropriate HCPCS codes.
706 SUBMIT WITH CMG
This is an acute rehab admit. Please resubmit claim with the appropriate case mix group code.
707 PAID AT CMG
This claim was reimbursed according to the CMS case mix group.
708 INCLUDED IN CMG
Reimbursement for this service in included in the CMG
810 SUBMIT TO DENTAL HEALTH VENDOR
Please submit this claim to the Dental Health Vendor.
812 NON PAR PROVIDER TIMELY FILING
All claims for non participating Providers must be submitted by 12/31 of the year following the year of
service, or by 12/31 of the second year for care rendered during the last 3 months of the year.
813 INPATIENT COPAYMENTS APPLY
The inpatient hospital co-pay applies to these inpatient hospital days.
814 INPATIENT DAYS EXHAUSTED
Inpatient hospital days have been exhausted.
855 CONTACT HEALTH SERVICES
Please contact our Health Services Department to discuss the Member's treatment.
877 NOT INCLUDED IN DENTAL BENEFIT
This service is not covered under the Member's dental benefit.
900 INCLUDED IN APC PRICE
Reimbursement for this service is included in the APC reimbursement.
999 ADJUSTMENT
This is an adjustment of a previously processed claim.
#C SYSTEM-CAPITATED SERVICE
Reimbursement for this claim is included in the capitation payment.
C CAPITATED SERVICE
Reimbursement for this claim is included in the capitation payment.
CG CLAIMSGUARD ADJUSTMENT
This claim has been reimbursed according to Medicare and Correct Coding Initiative rules. If you
disagree with this reimbursement, we will review the claim with additional supporting documentation.
