What to do when you see these adjustment codes
CO-119: When you see CO-119 check the consumer order to see if two orders was sent out in the same month, If two orders haven’t been sent out in the same month call Pennsylvania Medicaid (if you’re working on Pa claims). Billers should asked the Representative if another supplier billed for the procedure code, get the date the other supplier billed & contact a CSR so that products can be stopped from going out on the next order.
PI-16: When you see PI-16 the claim or line item has been denied or rejected & billers should pay very close to the second adjustment reason if one is provided. The second adjustment reason will tell you why the claim or line has been denied or rejected. You can use this web site for more details on the denial http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reasoncodes/
CO-24: If Medicaid deny or reject a claim and send a response with CO-24, That consumer has a MCO. The MCO is one that should be paying for the order, be aware that every MCO MSI is not in network with & if you find one that MSI isn’t contracted with, you should let a CSR know to hold any further orders because MSI is not contacted and out of network providers will not be paid.
CO-45: CO-45 means we billed more than the fee schedule price, any payment that is received nine out ten is the allowable amount that insurance company is willing to pay. There is nothing specific you need to do.
CO-109: CO-109 is basically a denial you would typically see from Medicare that states another insurance company should pick up the cost of this item because were not paying for it.
CO-29: As billers we should Never see CO-29, but in the cases that you do see this code its means the claim or line item you billed wasn’t billed with in the timely filling limits. Which means in some cases there is nothing you can do to get this claim or line item paid for * Billers should get to know there state or insurance companies timely filing limits so that this doesn’t Occur*
HE- N286: HE- N286 means Referring Provider’s NPI number is not on file, which means the consumer doctor is not enrolled which in this case Pennsylvania medicaid. Billiers should let a Csr know that we need a enrolled provider with Pennsylvania Medicaid in order to be paid.
CO-13: This adjustment code means the consumer passed away before the date of service. Make sure we have the Date of death to update our system.
HE-N330: This adjustment code means the consumer passed away before the date of service.
N30: This adjustment code means that when we billed Medicaid for the his/her supplies the consumer insurance was in a inactive state. In a few weeks after receiving this adjustment reason mark order as RB-NW.
PR-27 : This adjustment code means we sent a claim to a insurance company after the consumer has already terminated their coverage with them. Billing should call that insurance company and get the termination date so that we can update there account.
PR-26: This adjustment code means we have the wrong effective date in our system, biller’s should called the insurance company or use websites to get the correct effective date.
PR-31: This adjustment code the recipient id number we have in the system is not correct. Billiers should called the insurance company or use websites to get the correct recipient id number.
CO-96 / PR- 96: This adjustment code can mean two different things a good denial from a HMO/ Medigap/ Medicare or Medicare replacement Plan, this will cause the status of the line item or order to change to DN-CP . CO -96 can also mean the consumer is in a LTC RESIDENT or Inactive when the order was billed. Billiers should pay very close attention to the second adjustment reason if one is provided it will tell you exactly why that order or line item denied. If an order denied for being inactive this means paper work wasn’t submitted to the department of public welfare and the consumer account was marked as inactive. Billiers should give that order a few weeks before re billing 9 time out of 10 we can re bill and get paid for that order.
OA-18 / CO-18: This adjustment code means you billed a duplicate claim, More than likely we’ve already received a payment or a good denial for this order or line item.
CO-197: This adjustment code means that insurance company wants you to get a prior authorization for those products, we normally don’t get prior authorizations for a HMO/ Medigap/ Medicare replacement Plan. Billiers should try to get a authorization because I think that’s the only way we’re going to get a good denial.
CO-165: This adjustment code means the insurance company needs more information, a biller should re bill that claim to the insurance company & send the RX that the doctor sign off with the claim.
CO-140: This adjustment code the recipient id number &/or the consumer name we have in the system is not correct. Billiers should called the insurance company or use websites to make sure the recipient id number&/or the consumer name is correct in our system.
CO-B7: This adjustment code means Msi was not certified/ eligible to be paid for this procedure code. Billiers should wait until management let us know that we are certified/ eligible again and then re bill the order or line item for Medicare .
CO-11: This adjustment code means the diagnosis code is inconsistent with the procedure code. You will probably see more of this adjustment code with United health care community plan. Billiers should make sure that consumer has another diagnosis code that has nothing to do with incontinence, but is the cause as to why the consumer has incontinence.
N570: This adjustment code means Msi was not certified/ eligible to be paid for this procedure code. Billiers should wait until management let us know that we are certified/ eligible again and then rebill the order or line item.
CO-20: This adjustment code you will see at when you are working with Maryland Medicaid. This adjustment code means you have to send Maryland medicaid a copy of the consumer HMO/ Medigap &/ or Medicare replacement Plan EOB.