|
Hold Code |
Hold Message |
Explanation |
|
AB |
Admin Paid Via Immune service code |
Administration code not reimbursable must submit the immune code |
|
AD |
This Provider is no longer active |
Provider Relations code this provider is not active at this address or no longer in service |
|
AT |
EFT Provider |
Provider received electronic transfer (no paper check) |
|
AU |
Item included in other payment |
|
|
BA |
This admission was not Authorized |
Used to deny the claim when the required authorization was denied by the Utilization Department |
|
BC |
Pre and Post Operative Procedures are not covered |
Used to deny any charge identified as pre/post op visits |
|
BD |
Services Billed are not eligible for benefits |
The service rendered by the provider (procedure code) does not appear on that providers’ fee schedule as a payable service |
|
BF |
Abortion Certification form not submitted |
When the abortion certification is not received at the time claim was processed |
|
BG |
Services Billed are not compatible with diagnosis |
When the provider submits a claim with a diagnosis that is not covered by HP/SP |
|
BH |
Services billed are not part of the chiropractic benefit |
Services billed the are not part of the chiropractic benefit |
|
BI |
Non-covered pediatric service |
Services billed not eligible |
|
BJ |
Member not eligible for services billed |
Member not eligible for benefit |
|
BL |
Resubmit claim with sterilization consent form |
When the sterilization consent was not received |
|
BN |
Authorization was not obtained for these service |
|
|
BO |
Duplicate of a previously considered service |
The claim being denied is the exact duplicate of another claim already processed |
|
BR |
Service is part of per diem payment |
Denial used to identify ancillary services on Hospital IP/SPU claims |
|
BV |
Retraction of Previous payment |
Payment has been retracted due to service paid previously |
|
BW |
Resubmit charge with a valid procedure code |
Procedure code submitted not valid |
|
BX |
Adjust – Paid incorrect member |
Claim reprocessed due to processed under the incorrect member ID |
|
BY |
Adjust- Paid incorrect provider |
Claim reversed due to processed under the incorrect provider |
|
BZ |
Adjust- Paid incorrect provider |
Procedure reimbursed was paid in error |
|
CA |
Adjustment – Duplicate payment |
Service(s) retracted due to duplicate payment |
|
CB |
Adjustment – Previous Payment Incorrect |
Balance due previous payment was incorrect |
|
CG |
Original claims is pending review |
Second submission denied original claim pending review |
|
CH |
Payment retracted other insurance primary |
Payment retracted – the member has other insurance which is primary |
|
CI |
Forward claim to entry point at (888) 785-0600 |
Senior Partners only: Behavioral health claims are denied and should be submitted to Entry Point at Belmont |
|
CJ |
Submit claim to your mental health carrier |
Behavioral health claims are denied and should be submitted to the behavioral health plan |
|
CK |
Benefits previously paid to another OB provider |
Denial if benefits were previously paid to another OB provider |
|
CL |
Outreach bonus is N/C on same day as delivery |
This bonus is payable to the provider if a pregnant member receives care during the pregnancy. If the member does not receives care until the delivery the claim for the outreach bonus will be denied |
|
CM |
Intake is N/C when less than 4 weeks to delivery |
Denial when the intake is done less than 4 weeks form delivery, or if the service is billed with the delivery charge |
|
CN |
Please resubmit this claim with the DRG code |
Hospital claims submitted without a DRG code, are denied (resubmit claim with DRG code) |
|
CO |
Please resubmit service on a completed EPSDT for payment |
Service should be resubmitted on EPSDT From. – (not uses after March 2004 |
|
CP |
Payment reduced by coinsurance amount |
Provider reimbursement was reduced by the member’s coinsurance |
|
CQ |
No payment allowed – Provider sanction |
Provider has an active sanction |
|
CR |
Primary payment exceeds HP’s allowable benefit |
The primary payer reimbursement exceeds HP liability for consideration of deductible/coinsurance so no additional benefit is payable |
|
CS |
Maximum Benefit payable as secondary |
Payment for service has reached Health Partners allowable benefit reimbursement |
|
CU |
ER service is not covered when patient is admitted |
When a member is rendered service in the ER, and admitted to the same facility the ER service will be denied |
|
CV |
Insufficient pharmacy data |
|
|
CW |
Payment reduced by co-payment amount |
Provider reimbursement was reduced by the member’s co-payment |
|
CX |
Center of Excellence Member |
Provider should not bill this service |
|
DT |
Denied part of Mothers Case Rate |
Service denied – part of the contracted case rate included in the reimbursement for the Mothers charges |
|
DW |
Payment reduced by deductible amount |
Provider reimbursement was reduced by the member’s deductible amount |
|
DZ |
Service paid per individual visit only |
Service(s) submitted are only considered if billed individually |
|
EC |
Claims Appeal Approved |
Claim approved for reconsideration |
|
EE |
Claim Appeal Denied |
Claim approved for reconsideration |
|
EF |
Adjustment paid Incorrectly |
The service submitted fee has been updated by Provider reimbursement |
|
EH |
Appeal Denied Untimely |
Claim did not meet the timely filing guidelines for reconsideration |
|
EM |
Medical record required for outlier days |
Medical record required for outlier days to be considered |
|
EQ |
Not-Covered Service Included in VFC (vaccine free for children) program |
Not-Covered Service Included in VFC (vaccine free for children) program |
|
ES |
Resubmit with invoice – Service should be billed with the invoice |
The service was contracted to be submitted with the invoice and not received |
|
EU |
Unprocessable required information needed |
Claim unprocessable additional information needed |
|
EV |
HB form req/+4wks from delivery |
HB form is required for more than 4 weeks from delivery |
|
EY |
Healthy Babies Form Required for service |
Healthy Babies form required for reimbursement |
|
FB |
Non-Covered diagnosis on Senior Partners/Health Partners member |
Diagnosis not covered for dully enrolled member |
|
FD |
Unauthorized service for nonparticipating provider |
Non-Par provider no authorization |
|
FG |
Senior Partners member not eligible for benefits |
Dually enrolled member not eligible for benefits. |
|
FH |
Complaint and Grievance First Level Appeal Approved |
First level appeal approved |
|
FI |
Complaint and Grievance Second Level Appeal Approved |
Second level appeal approved |
|
FJ |
Complaint and Grievance First Level Appeal Denied |
First level Appeal denied |
|
FK |
Complaint and Grievance Second Level Appeal Denied |
Second Appeal level denied |
|
FM |
Service not payable by the health plan |
Service not payable by the Plan |
|
FN |
Authorization Canceled by Utilization Management |
Authorization has been canceled by UM |
|
FP |
Denied Readmit within 7 days |
Re-admit within 7 days of inpatient stay |
|
FY |
Implants under $500 not covered |
Implants under $500.00 not covered |
|
GA |
Initial decision for this claim has been upheld |
Used when a claim is resubmitted for review, and the original claim decision stands |
|
GB |
These charges must be submitted on a HCFA1500 form |
Resubmit on CMS 1500 Form |
|
GC |
Cost Report Needed For DRG |
Cost report needed for Finance |
|
GE |
Requested information not received from member |
COB claims will be denied in the system if requested additional information, such as the primary carrier’s EOB or letter of declination, are not received by Health Partners |
|
GI |
Late charges were included in the original payment |
When the facility submits late charges |
|
GR |
Adjustment – COB incorrectly applied |
Claim reprocessed and COB reapplied |
|
GS |
Resubmit with a valid diagnosis code |
When the claims is submitted with an invalid diagnosis code the entire claim will be denied |
|
GU |
Requested provider information was never received |
Provider Data Base missing provider information |
|
GY |
Submit this claim to Doral |
Resubmit to Doral |
|
HA |
Provider has not been credentialed for the service |
Provider has not been credentialed for submitting service(s) |
|
HC |
NON-HIPPA Complaint code. Rebill valid code |
NON-HIPPA Compliant rebel with valid code |
|
HD |
Missing/incomplete/invalid prior insur carrier EOP |
Provider has not submitted the primary carriers EOB for consideration |
|
HF |
Outlier Days Under Review |
Outlier days are under review by Health Partners Utilization Management |
|
HG |
Complaint EPSDT code required |
Submitting with non-complaint EPSDT code |
|
HH |
Outlier Days Denied by Health Partners Utilization Management |
Outlier days have been denied by Health Partners Utilization Management |
|
HJ |
Anesthesia Records Not Submitted |
Requesting Anesthesia records to be submitted and not received |
|
HK |
Outlier Days Approved |
Outlier days has been approved for reimbursement |
|
HL |
Claim paid to a different site same Doctor/paid to different site within your billing network |
Claim paid to a different site same Doctor/paid to different site within your billing network |
|
HO |
MDCR-NON Covered SP Benefit |
Service billed are not eligible |
|
HQ |
MDCD-NON Covered HP Benefit |
Service billed are not eligible |
|
HS |
Claim is pending review |
Claim has been denied pending review – (Refer to SIU -Claims Department) |
|
HT |
E/M code(s) not submitted for completed EPSDT submission |
E/M code(s) not submitted for completed EPSDT submission |
|
HU |
Anesthesia modifier required |
Anesthesiologist billing without required modifier(s) |
|
HV |
Incorrect NDC submitted |
The incorrect NDC was submitted for reimbursement |
|
HW |
Incorrect anesthesia units |
Incorrect submission of anesthesia units submitted only time units should be submitted |
|
JA |
Prior payment included this service |
Used to auto deny claims when the provider has received a settlement for a specific time frame |
|
JM |
Provider not participating in the Medicaid program |
Provider submitting is not in the MA program |
|
JN |
Medical Records required by Utilization Management for consideration |
Medical records required for consideration – send to UM dept |
|
JO |
Level of care not authorized |
Used to deny a level of care that was not authorized by Utilization Management Department |
|
JP |
Service level approved by plan |
Used when a different level of care is approved by Utilization Management Department other then what has been submitted by the provider |
|
JS |
Therapy benefit not covered |
Therapy benefit not covered by the plan |
|
JU |
Invalid rev/proc code combo |
Used to deny a invalid revenue/procedure code combination submitted by the provider |
|
JV |
Rebill using codes 90471/90472 |
PCP resubmit with appropriate code |
|
JY |
Recipient Statement Not Received |
Member statement not received |
|
KC |
Non-Specific Diagnosis (4th or 5th digit required) |
Non-Specific Diagnosis (4th or 5th digit required |
|
LA |
RA-Multiple proc/serv paid |
Multiple procedures and services paid |
|
LB |
RA-Multiple prov/sites paid same service |
Multiple providers and sites paid for the same service |
|
LC |
RA-Retrodisenrolled member |
The member was reto – disenrolled form the plan |
|
LD |
RA-No auth/denied auth on file |
Services not authorized or authorization denied |
|
LE |
RA-claim overpayment |
Claim was overpaid |
|
LF |
RA-Baby claim paid under mom’s ID |
Claim was paid under the mothers claim submission |
|
LG |
RA-paid above billed amount |
The claim was overpaid above the billed amount |
|
LH |
RA-incorrect units paid |
Over paid due to units |
|
LI |
RA-provider vin/tin id change |
Provider vendor Tax ID changed |
|
LK |
RA-other party responsible |
Other party responsible for chargers |
|
LL |
RA-COB primary Medicare Liable |
Retracted Medicare is primary |
|
LM |
RA-Primary Commercial insurance Liable |
Retracted Commercial insurance is primary |
|
LN |
RA-dual eligible SR and HP |
Dual enrolled with Senior Partners and Health Partners |
|
MG |
Criteria for SPU not MET |
The services submitted does not meet the SPU criteria for reimbursement |
|
MH |
Services not contracted |
Services submitted are not contracted for this provider |
|
OC |
Service rendered is included in the APNEA program |
|
|
PV |
Submit under physician ID number |
Claim must be submitted under the physician’s ID number |
|
QS |
Provider no longer participates in HP network |
Provider no longer participates in the plan |
|
RG |
Retraction of HP overpay – PCH |
Retraction of overpayment |
|
RV |
Modifier invalid for service |
Modifier invalid for submitted service |
|
SB |
Service is included in case rate |
This service is part to a case rate |
|
SK |
Service paid correctly |
Appeal – services paid correctly |
|
SL |
Claim Reprocessed |
Claim will be reprocessed |
|
SR |
Pending UM case Review |
Untimely response to denial |
|
ST |
Capitated Service |
Capitated service |
|
SW |
Benefit applied to member copay |
Used when SP payment = 0, and the benefit was applied to the members’ co-pay |
|
SX |
Non Par out patient services with no authorization |
Denial for non-par providers’ with no authorization in the MHS system (all non-par providers require authorization form UM) |
|
SZ |
Post-Partum care not covered after 6 weeks. |
|
|
XD |
Duplicate of another charge |
Duplicate charge |
|
XG |
Considered part of global service |
Part of a code that has been paid, either on the same claim or on another claim |
|
XI |
Incidental to primary procedure |
Part of a code that has been paid, either on the same claim or on another claim |
|
XO |
One visit code allowed per day |
CPT guidelines indicate that only one visit code should be billed per day with all service combined into the most appropriate code. Visits may have been billed on separate claims |
|
XP |
Primary Code Not Included |
Primary code not included with the service submitted. Claims denied with Recovery codes should be submitted to that Department for handling. All X codes |
|
XR |
Part of a more comprehensive code |
Used for codes Rebundled to XM code. The codes are denied and replaced with the more comprehensive code |
|
XT |
Code cannot be accepted twice |
This code can only be billed once |
|
XW |
Code includes multiple session |
Includes multiple sessions within a particular time frame |
|
B2 |
Service is included in lab capitation |
Lab service included in cap |
|
B3 |
PCP non-reimbursable services |
Not reimbursable to the PCP |
|
B4 |
CORF service not eligible for service |
Service not eligible for benefits |
|
B5 |
Ped service 20-99 not eligible for benefit |
Age invalid for benefit |
|
B6 |
Sterilization 0-20 not eligible for benefit |
Age invalid for benefit |
|
Y1 |
Age To Procedure: denied “HPR Message # |
HPR code review – will review the members age according to the procedure submitted, if the members’ age is not appropriate with the procedure the claim will deny |
|
Y2 |
Assist Surgeon: denied “HPR Message # |
Charges for assist surgeons’ will deny according to HPR code review |
|
Y6 |
Diag To Proc: denied “HPR Message # |
Diagnosis not appropriate with the procedure submitted |
|
Y7 |
Sex to Procedure: denied “HPR” Message # |
HPR code review – will review the members sex according to the procedure submitted, if the members’ sex is not appropriate with the procedure the claim will deny |
|
YB |
Old Code – Bill with new CPT code |
Based on the year of service, if an old procedure code is no longer valid HPR code review will deny the service, the provider should submit with a valid code. |
|
YC |
Claim Supervisor Review – Undefined procedure unable to determine code |
Procedure that are undefined according to HPR code review will auto deny, and unable to determine the code |
|
YD |
Denied by HPR Message # |
HPR code review message undefined on EOP. The message number will be indicated on that service line, use HP1011 and the code to determine denial |
|
YX |
Default – See HPR Message # (call Provider Help Line) |
|
|
03 |
Member was not eligible on the date of service |
Member was not covered under the HP or SP plan on the date service was rendered |
|
07 |
Procedure(s) not appropriate for patient’s age |
If the members’ age is not appropriate with the procedure the claim will deny |
|
09 |
Procedure(s) not appropriate for patient’s sex |
If the members’ sex is not appropriate with the procedure the claim will deny |
|
11 |
This rental has exceeded the purchase price |
When the provider submits an amount that has exceeded what Utilization Management has approved, the claim will only pay the approved amount and deny the balance |
|
12 |
Member not part of PCP’s panel on date of service |
If the service was rendered prior to the effective date of the member’s PCP the claim will deny |
|
13 |
Service invalid for Prv/Vendor |
|
|
16 |
Resubmit claim with the primary insurance EOB |
HP records indicate another insurance (usually Medicare or the Blues) has primary responsibility for the service being billed |
|
17 |
Benefit invalid based on the member’s sex |
If the members’ sex is not appropriate with the benefit the claim will deny |
|
18 |
Benefit invalid based on the member’s age |
If the members’ age is not appropriate with the benefit the claim will deny |
|
19 |
Units billed exceed the number of units approved |
When the provider submits units greater that the units approved by the Utilization Management department, the claim will only pay the approved amount of units and deny the balance |
|
21 |
Service included in Pricer |
|
|
26 |
Claim exceeds timely filing limit |
Claim is denied for untimely filing – 180 days exceeded between date of service and date of claim receipt |
|
27 |
Outside claim future period |
When the claim was submitted before the date of service was rendered |
|
34 |
Diagnosis is not appropriate for patient’s age |
Members’ age is inappropriate for the diagnosis submitted |
|
35 |
Diagnosis is not appropriate for patient’s sex |
Members’ sex is inappropriate for the diagnosis submitted |
|
37 |
Group coverage not effective on date of service |
Member not effective on date of service |
|
38 |
Coverage dollar limit exceeded |
Charges exceed benefit limit |
|
39 |
Coverage service limits exceeded |
Member units exceed benefit limit |
|
43 |
Service code not effective for date of service |
The submitted code is not effective for the date of service being rendered |
|
44 |
Diagnosis code not effective for date of service |
The submitted diagnosis code is not effective for the date of service being rendered |
|
45 |
Service rendered after member’s termination date |
Member terminated on date of service |
|
64 |
These inpatient days are not authorized |
The days that exceed the authorized amount of time will be denied |
|
69 |
Authorization was not obtained for these service |
Precert not on file |
|
82 |
Rental purchase price met |
The rent to purchase price has been met |
|
83 |
Rental Purchase Price Exceeded |
Rental price has exceeded the purchase price |
|
99 |
Exact Duplicate |
The claim being denied is the exact duplicate of another claim already processed in MHS |