Reason codes
Claim adjustment reason codes (CARC)
164 reason codes, each with Rivvi's plain-English meaning. X12's exact wording is on x12.org.
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Numbered codes
- 1DeductiblePR-1
- 2CoinsurancePR-2
- 3CopayPR-3
- 4Modifier missing or does not fit the codeCO-4
- 5Code does not fit the place of serviceCO-5
- 6Code does not fit the patient's ageCO-6
- 7Code does not fit the patient's sexCO-7
- 8Code does not fit the provider type or specialtyCO-8
- 9Diagnosis does not fit the patient's ageCO-9
- 10Diagnosis does not fit the patient's sexCO-10
- 11Diagnosis does not support the procedureCO-11
- 12Diagnosis does not fit the provider typeCO-12
- 13Date of death before date of serviceCO-13
- 14Date of birth after date of serviceCO-14
- 16Missing or wrong information on the claimCO-16
- 18Exact duplicate claim or serviceCO-18
- 19Work-related injuryCO-19
- 20Liability carrier should payCO-20
- 21No-fault carrier should payCO-21
- 22Another payer may be primaryCO-22
- 23Adjusted for the prior payer's paymentOA-23
- 24Covered under a capitation agreementCO-24
- 26Service before coverage startedCO-26
- 27Service after coverage endedCO-27
- 29Timely filing limit passedCO-29
- 31Patient not found as a memberCO-31
- 32Not an eligible dependentCO-32
- 33No dependent coverageCO-33
- 34No newborn coverageCO-34
- 35Lifetime maximum reachedCO-35
- 39Authorization was deniedCO-39
- 40Not an emergency or urgent visitCO-40
- 45Charge over the allowed amountCO-45
- 49Routine or preventive service not coveredCO-49
- 50Not medically necessaryCO-50
- 51Pre-existing conditionCO-51
- 53Service by a relative not coveredCO-53
- 54Assistant or multiple surgeons not coveredCO-54
- 55Experimental or investigationalCO-55
- 56Not proven effectiveCO-56
- 58Wrong place of serviceCO-58
- 59Multiple or concurrent procedure reductionCO-59
- 60Outpatient service near an inpatient stayCO-60
- 61No second surgical opinionCO-61
- 66Blood deductiblePR-66
- 89Professional fees removedCO-89
- 94Paid more than the chargeCO-94
- 95Plan procedures not followedCO-95
- 96Non-covered chargeCO-96
- 97Included in another serviceCO-97
- 100Paid to the patientOA-100
- 101Predetermination estimateOA-101
- 107Related claim not foundCO-107
- 108Rental or purchase rules not metCO-108
- 109Wrong payerCO-109
- 110Billed before the service dateCO-110
- 111Provider must accept assignmentCO-111
- 112Not given directly or not documentedCO-112
- 114Not approved by the FDACO-114
- 115Procedure postponed or canceledCO-115
- 116Patient notice did not meet the rulesCO-116
- 117Transport only to the closest facilityCO-117
- 119Benefit maximum for the period reachedCO-119
- 128Newborn covered in the mother's paymentCO-128
- 129Prior processing looks wrongCO-129
- 130Claim submission feeCO-130
- 131Negotiated discountCO-131
- 133Pending further reviewOA-133
- 135Interim bills cannot be processedCO-135
- 136Prior payer's rules not followedCO-136
- 140Patient name and ID do not matchCO-140
- 146Diagnosis invalid for the date of serviceCO-146
- 147Contract rate expired or not on fileCO-147
- 148Information from another provider missingCO-148
- 149Lifetime maximum for this service reachedCO-149
- 150Level of service not supportedCO-150
- 151Number or frequency of services not supportedCO-151
- 152Length of service not supportedCO-152
- 153Dosage not supportedCO-153
- 154Days' supply not supportedCO-154
- 155Patient refused the serviceCO-155
- 163Attachment not receivedCO-163
- 164Attachment received lateCO-164
- 166Sent after the payer's responsibility endedCO-166
- 167Diagnosis not coveredCO-167
- 169Alternate benefit givenCO-169
- 170Not paid when billed by this provider typeCO-170
- 171Not paid for this provider in this facilityCO-171
- 172Not paid for this specialtyCO-172
- 173Not prescribed by a physicianCO-173
- 174Not prescribed before deliveryCO-174
- 175Prescription incompleteCO-175
- 176Prescription not currentCO-176
- 177Eligibility requirements not metCO-177
- 178Spend-down not metCO-178
- 179Waiting period not metCO-179
- 180Residency requirement not metCO-180
- 181Procedure code invalid on the date of serviceCO-181
- 182Modifier invalid on the date of serviceCO-182
- 183Referring provider not eligibleCO-183
- 184Ordering provider not eligibleCO-184
- 185Rendering provider not eligibleCO-185
- 189Unlisted code used when a specific code existsCO-189
- 190Included in a skilled nursing stayCO-190
- 193Original decision kept on reviewOA-193
- 194Anesthesia by the surgeonCO-194
- 197Authorization missingCO-197
- 198Authorization exceededCO-198
- 199Revenue code and procedure code do not matchCO-199
- 200Lapse in coverageCO-200
- 202Personal comfort item not coveredCO-202
- 203Discontinued or reduced serviceCO-203
- 204Not covered by the current planCO-204
- 206NPI missingCO-206
- 207NPI invalidCO-207
- 208NPI does not matchCO-208
- 209Provider cannot collect from the patientCO-209
- 210Authorization not received in timeCO-210
- 213Self-referral ruleCO-213
- 216Review organization findingCO-216
- 222Over the contracted maximumCO-222
- 226Requested information not sentCO-226
- 227Patient did not send requested informationCO-227
- 228Information not given to a prior payerCO-228
- 231Mutually exclusive proceduresCO-231
- 233Hospital-acquired conditionCO-233
- 234Not paid separatelyCO-234
- 235Sales taxCO-235
- 236Procedure or modifier pair not compatibleCO-236
- 239Claim spans covered and non-covered datesCO-239
- 242Not by a network or primary care providerCO-242
- 243Not authorized by the network or primary care providerCO-243
- 246Reporting-only codeCO-246
- 249ReadmissionCO-249
- 250Wrong attachment receivedCO-250
- 251Attachment missing required contentCO-251
- 252Attachment neededCO-252
- 253SequestrationCO-253
- 256Not payable under the managed care contractCO-256
- 258Patient in custodyCO-258
- 261Inconsistent with the patient's historyCO-261
- 272Coverage guidelines not metCO-272
- 273Coverage guidelines exceededCO-273
- 275Prior payer's patient share not coveredCO-275
- 276Services the prior payer denied not coveredCO-276
- 286Appeal time limit not metCO-286
- 287Referral exceededCO-287
- 288Referral missingCO-288
Lettered codes
- A1Claim or service deniedCO-A1
- B1Non-covered visitsCO-B1
- B4Late filing penaltyCO-B4
- B7Provider not certified for this service on this dateCO-B7
- B8Alternative services were availableCO-B8
- B9Patient enrolled in hospiceCO-B9
- B10Reduced because a component was paidCO-B10
- B11Sent to the right payerCO-B11
- B12Not documented in the recordCO-B12
- B13Previously paidCO-B13
- B14One visit per physician per dayCO-B14
- B15Qualifying service missingCO-B15
- B16New patient rules not metCO-B16
- B20Furnished by another providerCO-B20
- B22Adjusted for the diagnosisCO-B22
- B23Not allowed under the lab's CLIA certificateCO-B23