Understanding Denial Codes Related to CMS-1500 Submissions

Denial codes associated with CMS-1500 submissions indicate why a claim was rejected or denied by a payer. Understanding these codes helps in identifying errors, correcting claims, and resubmitting them for reimbursement.

Common Denial Codes and Their Meanings

1. CO (Contractual Obligation) Codes:
   • CO-16: Claim lacks information or has missing/incorrect information.
     • Example: Missing diagnosis code or patient details.
     • Action: Review the Explanation of Benefits (EOB) or Remittance Advice (RA) for details, correct errors, and resubmit.
   • CO-45: Charge exceeds contracted/allowed amount.
     • Action: Write off the excess per the contract with the payer.
2. PR (Patient Responsibility) Codes:
   • PR-1: Deductible amount not met.
     • Action: Notify the patient of their financial responsibility.
   • PR-2: Coinsurance amount due.
     • Action: Bill the patient for their share.
3. OA (Other Adjustment) Codes:
   • OA-18: Duplicate claim/service.
     • Action: Check if the claim was already processed and avoid resubmitting duplicates.
   • OA-109: Claim/service not covered by this payer.
     • Action: Verify if the payer is responsible for coverage or bill the appropriate secondary insurer.
4. CR (Correction Required) Codes:
   • CR-27: Missing or invalid modifier.
     • Action: Verify and add the correct CPT/HCPCS modifier.
5. MA (Medicare-Specific) Codes:
   • MA-130: Claim denied as it does not meet the requirements of a Medicare policy.
     • Action: Review Medicare guidelines for the specific service and resubmit with proper documentation.
6. N (Informational) Codes:
   • N95: Service not covered because it is considered experimental or investigational.
     • Action: Appeal with supporting medical documentation or explain non-coverage to the patient.