| 0 | Cannot provide further status electronically. Start: 1/1/1995 |
| 1 | For more detailed information, see remittance advice. Start: 1/1/1995 |
| 2 | More detailed information in letter. Start: 1/1/1995 |
| 3 | Claim has been adjudicated and is awaiting payment cycle. Start: 1/1/1995 |
| 4 | This is a subsequent request for information from the original request. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 5 | This is a final request for information. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 6 | Balance due from the subscriber. Start: 1/1/1995 |
| 7 | Claim may be reconsidered at a future date. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 8 | No payment due to contract/plan provisions. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 9 | No payment will be made for this claim. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 10 | All originally submitted procedure codes have been combined. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 11 | Some originally submitted procedure codes have been combined. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 12 | One or more originally submitted procedure codes have been combined. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 13 | All originally submitted procedure codes have been modified. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 14 | Some all originally submitted procedure codes have been modified. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 15 | One or more originally submitted procedure code have been modified. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 16 | Claim/encounter has been forwarded to entity. Start: 1/1/1995 |
| 17 | Claim/encounter has been forwarded by third party entity to entity. Start: 1/1/1995 |
| 18 | Entity received claim/encounter, but returned invalid status. Start: 1/1/1995 |
| 19 | Entity acknowledges receipt of claim/encounter. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 20 | Accepted for processing. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 21 | Missing or invalid information. Note: At least one other status code is required to identify the missing or invalid information. Start: 1/1/1995 | Last Modified: 7/9/2007 |
| 22 | ... before entering the adjudication system. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 23 | Returned to Entity. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 24 | Entity not approved as an electronic submitter. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 25 | Entity not approved. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 26 | Entity not found. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 27 | Policy canceled. Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 28 | Claim submitted to wrong payer. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 29 | Subscriber and policy number/contract number mismatched. Start: 1/1/1995 |
| 30 | Subscriber and subscriber id mismatched. Start: 1/1/1995 |
| 31 | Subscriber and policyholder name mismatched. Start: 1/1/1995 |
| 32 | Subscriber and policy number/contract number not found. Start: 1/1/1995 |
| 33 | Subscriber and subscriber id not found. Start: 1/1/1995 |
| 34 | Subscriber and policyholder name not found. Start: 1/1/1995 |
| 35 | Claim/encounter not found. Start: 1/1/1995 |
| 37 | Predetermination is on file, awaiting completion of services. Start: 1/1/1995 |
| 38 | Awaiting next periodic adjudication cycle. Start: 1/1/1995 |
| 39 | Charges for pregnancy deferred until delivery. Start: 1/1/1995 |
| 40 | Waiting for final approval. Start: 1/1/1995 |
| 41 | Special handling required at payer site. Start: 1/1/1995 |
| 42 | Awaiting related charges. Start: 1/1/1995 |
| 44 | Charges pending provider audit. Start: 1/1/1995 |
| 45 | Awaiting benefit determination. Start: 1/1/1995 |
| 46 | Internal review/audit. Start: 1/1/1995 |
| 47 | Internal review/audit - partial payment made. Start: 1/1/1995 |
| 48 | Referral/authorization. Start: 1/1/1995 | Last Modified: 2/28/2001 |
| 49 | Pending provider accreditation review. Start: 1/1/1995 |
| 50 | Claim waiting for internal provider verification. Start: 1/1/1995 |
| 51 | Investigating occupational illness/accident. Start: 1/1/1995 |
| 52 | Investigating existence of other insurance coverage. Start: 1/1/1995 |
| 53 | Claim being researched for Insured ID/Group Policy Number error. Start: 1/1/1995 |
| 54 | Duplicate of a previously processed claim/line. Start: 1/1/1995 |
| 55 | Claim assigned to an approver/analyst. Start: 1/1/1995 |
| 56 | Awaiting eligibility determination. Start: 1/1/1995 |
| 57 | Pending COBRA information requested. Start: 1/1/1995 |
| 59 | Non-electronic request for information. Start: 1/1/1995 |
| 60 | Electronic request for information. Start: 1/1/1995 |
| 61 | Eligibility for extended benefits. Start: 1/1/1995 |
| 64 | Re-pricing information. Start: 1/1/1995 |
| 65 | Claim/line has been paid. Start: 1/1/1995 |
| 66 | Payment reflects usual and customary charges. Start: 1/1/1995 |
| 67 | Payment made in full. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 68 | Partial payment made for this claim. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 69 | Payment reflects plan provisions. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 70 | Payment reflects contract provisions. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 71 | Periodic installment released. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 72 | Claim contains split payment. Start: 1/1/1995 |
| 73 | Payment made to entity, assignment of benefits not on file. Start: 1/1/1995 |
| 78 | Duplicate of an existing claim/line, awaiting processing. Start: 1/1/1995 |
| 81 | Contract/plan does not cover pre-existing conditions. Start: 1/1/1995 |
| 83 | No coverage for newborns. Start: 1/1/1995 |
| 84 | Service not authorized. Start: 1/1/1995 |
| 85 | Entity not primary. Start: 1/1/1995 |
| 86 | Diagnosis and patient gender mismatch. Start: 1/1/1995 | Last Modified: 2/28/2000 |
| 87 | Denied: Entity not found. (Use code 26 with appropriate Claim Status category Code) Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 88 | Entity not eligible for benefits for submitted dates of service. Start: 1/1/1995 |
| 89 | Entity not eligible for dental benefits for submitted dates of service. Start: 1/1/1995 |
| 90 | Entity not eligible for medical benefits for submitted dates of service. Start: 1/1/1995 |
| 91 | Entity not eligible/not approved for dates of service. Start: 1/1/1995 |
| 92 | Entity does not meet dependent or student qualification. Start: 1/1/1995 |
| 93 | Entity is not selected primary care provider. Start: 1/1/1995 |
| 94 | Entity not referred by selected primary care provider. Start: 1/1/1995 |
| 95 | Requested additional information not received. Start: 1/1/1995 | Last Modified: 7/9/2007 Note: If known, the payer must report a second claim status code identifying the requested information. |
| 96 | No agreement with entity. Start: 1/1/1995 |
| 97 | Patient eligibility not found with entity. Start: 1/1/1995 |
| 98 | Charges applied to deductible. Start: 1/1/1995 |
| 99 | Pre-treatment review. Start: 1/1/1995 |
| 100 | Pre-certification penalty taken. Start: 1/1/1995 |
| 101 | Claim was processed as adjustment to previous claim. Start: 1/1/1995 |
| 102 | Newborn's charges processed on mother's claim. Start: 1/1/1995 |
| 103 | Claim combined with other claim(s). Start: 1/1/1995 |
| 104 | Processed according to plan provisions. This change to be effective 1/1/2009: Processed according to plan provisions (Plan refers to provisions that exist between the Health Plan and the Consumer or Patient) Start: 1/1/1995 | Last Modified: 6/1/2008 |
| 105 | Claim/line is capitated. Start: 1/1/1995 |
| 106 | This amount is not entity's responsibility. Start: 1/1/1995 |
| 107 | Processed according to contract/plan provisions. This change to be effective 1/1/2009: Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services) Start: 1/1/1995 | Last Modified: 6/1/2008 |
| 108 | Coverage has been canceled for this entity. (Use code 27) Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 109 | Entity not eligible. Start: 1/1/1995 |
| 110 | Claim requires pricing information. Start: 1/1/1995 |
| 111 | At the policyholder's request these claims cannot be submitted electronically. Start: 1/1/1995 |
| 112 | Policyholder processes their own claims. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 113 | Cannot process individual insurance policy claims. Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 114 | Should be handled by entity. This change to be effective 7/1/2008: Claim/service should be processed by entity. Start: 1/1/1995 | Last Modified: 1/27/2008 |
| 115 | Cannot process HMO claims Start: 1/1/1995 | Stop: 7/1/2008 | Last Modified: 1/27/2008 |
| 116 | Claim submitted to incorrect payer. Start: 1/1/1995 |
| 117 | Claim requires signature-on-file indicator. Start: 1/1/1995 |
| 118 | TPO rejected claim/line because payer name is missing. (Use status code 21 and status code 125 with entity code IN) Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 119 | TPO rejected claim/line because certification information is missing. (Use status code 21 and status code 252) Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 120 | TPO rejected claim/line because claim does not contain enough information. (Use status code 21) Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 121 | Service line number greater than maximum allowable for payer. Start: 1/1/1995 |
| 122 | Missing/invalid data prevents payer from processing claim. (Use CSC Code 21) Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 123 | Additional information requested from entity. Start: 1/1/1995 |
| 124 | Entity's name, address, phone and id number. Start: 1/1/1995 |
| 125 | Entity's name. Start: 1/1/1995 |
| 126 | Entity's address. Start: 1/1/1995 |
| 127 | Entity's phone number. Start: 1/1/1995 |
| 128 | Entity's tax id. Start: 1/1/1995 |
| 129 | Entity's Blue Cross provider id Start: 1/1/1995 |
| 130 | Entity's Blue Shield provider id Start: 1/1/1995 |
| 131 | Entity's Medicare provider id. Start: 1/1/1995 |
| 132 | Entity's Medicaid provider id. Start: 1/1/1995 |
| 133 | Entity's UPIN Start: 1/1/1995 |
| 134 | Entity's CHAMPUS provider id. Start: 1/1/1995 |
| 135 | Entity's commercial provider id. Start: 1/1/1995 |
| 136 | Entity's health industry id number. Start: 1/1/1995 |
| 137 | Entity's plan network id. Start: 1/1/1995 |
| 138 | Entity's site id . Start: 1/1/1995 |
| 139 | Entity's health maintenance provider id (HMO). Start: 1/1/1995 |
| 140 | Entity's preferred provider organization id (PPO). Start: 1/1/1995 | Last Modified: 6/30/2001 |
| 141 | Entity's administrative services organization id (ASO). Start: 1/1/1995 |
| 142 | Entity's license/certification number. Start: 1/1/1995 |
| 143 | Entity's state license number. Start: 1/1/1995 |
| 144 | Entity's specialty license number. Start: 1/1/1995 |
| 145 | Entity's specialty/taxonomy code. Start: 1/1/1995 | Last Modified: 9/30/2007 |
| 146 | Entity's anesthesia license number. Start: 1/1/1995 |
| 147 | Entity's qualification degree/designation (e.g. RN,PhD,MD) Start: 2/28/1997 |
| 148 | Entity's social security number. Start: 1/1/1995 |
| 149 | Entity's employer id. Start: 1/1/1995 |
| 150 | Entity's drug enforcement agency (DEA) number. Start: 1/1/1995 |
| 152 | Pharmacy processor number. Start: 1/1/1995 |
| 153 | Entity's id number. Start: 1/1/1995 |
| 154 | Relationship of surgeon & assistant surgeon. Start: 1/1/1995 |
| 155 | Entity's relationship to patient Start: 1/1/1995 |
| 156 | Patient relationship to subscriber Start: 1/1/1995 |
| 157 | Entity's Gender Start: 1/1/1995 |
| 158 | Entity's date of birth Start: 1/1/1995 |
| 159 | Entity's date of death Start: 1/1/1995 |
| 160 | Entity's marital status Start: 1/1/1995 |
| 161 | Entity's employment status Start: 1/1/1995 |
| 162 | Entity's health insurance claim number (HICN). Start: 1/1/1995 |
| 163 | Entity's policy number. Start: 1/1/1995 |
| 164 | Entity's contract/member number. Start: 1/1/1995 |
| 165 | Entity's employer name, address and phone. Start: 1/1/1995 |
| 166 | Entity's employer name. Start: 1/1/1995 |
| 167 | Entity's employer address. Start: 1/1/1995 |
| 168 | Entity's employer phone number. Start: 1/1/1995 |
| 169 | Entity's employer id. Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 170 | Entity's employee id. Start: 1/1/1995 |
| 171 | Other insurance coverage information (health, liability, auto, etc.). Start: 1/1/1995 |
| 172 | Other employer name, address and telephone number. Start: 1/1/1995 |
| 173 | Entity's name, address, phone, gender, DOB, marital status, employment status and relation to subscriber. Start: 1/1/1995 | Last Modified: 2/28/2000 |
| 174 | Entity's student status. Start: 1/1/1995 |
| 175 | Entity's school name. Start: 1/1/1995 |
| 176 | Entity's school address. Start: 1/1/1995 |
| 177 | Transplant recipient's name, date of birth, gender, relationship to insured. Start: 1/1/1995 | Last Modified: 2/28/2000 |
| 178 | Submitted charges. Start: 1/1/1995 |
| 179 | Outside lab charges. Start: 1/1/1995 |
| 180 | Hospital s semi-private room rate. Start: 1/1/1995 |
| 181 | Hospital s room rate. Start: 1/1/1995 |
| 182 | Allowable/paid from primary coverage. Start: 1/1/1995 |
| 183 | Amount entity has paid. Start: 1/1/1995 |
| 184 | Purchase price for the rented durable medical equipment. Start: 1/1/1995 |
| 185 | Rental price for durable medical equipment. Start: 1/1/1995 |
| 186 | Purchase and rental price of durable medical equipment. Start: 1/1/1995 |
| 187 | Date(s) of service. Start: 1/1/1995 |
| 188 | Statement from-through dates. Start: 1/1/1995 |
| 189 | Facility admission date Start: 1/1/1995 | Last Modified: 10/31/2006 |
| 190 | Facility discharge date Start: 1/1/1995 | Last Modified: 10/31/2006 |
| 191 | Date of Last Menstrual Period (LMP) Start: 2/28/1997 |
| 192 | Date of first service for current series/symptom/illness. Start: 1/1/1995 |
| 193 | First consultation/evaluation date. Start: 2/28/1997 |
| 194 | Confinement dates. Start: 1/1/1995 |
| 195 | Unable to work dates. Start: 1/1/1995 |
| 196 | Return to work dates. Start: 1/1/1995 |
| 197 | Effective coverage date(s). Start: 1/1/1995 |
| 198 | Medicare effective date. Start: 1/1/1995 |
| 199 | Date of conception and expected date of delivery. Start: 1/1/1995 |
| 200 | Date of equipment return. Start: 1/1/1995 |
| 201 | Date of dental appliance prior placement. Start: 1/1/1995 |
| 202 | Date of dental prior replacement/reason for replacement. Start: 1/1/1995 |
| 203 | Date of dental appliance placed. Start: 1/1/1995 |
| 204 | Date dental canal(s) opened and date service completed. Start: 1/1/1995 |
| 205 | Date(s) dental root canal therapy previously performed. Start: 1/1/1995 |
| 206 | Most recent date of curettage, root planing, or periodontal surgery. Start: 1/1/1995 |
| 207 | Dental impression and seating date. Start: 1/1/1995 |
| 208 | Most recent date pacemaker was implanted. Start: 1/1/1995 |
| 209 | Most recent pacemaker battery change date. Start: 1/1/1995 |
| 210 | Date of the last x-ray. Start: 1/1/1995 |
| 211 | Date(s) of dialysis training provided to patient. Start: 1/1/1995 |
| 212 | Date of last routine dialysis. Start: 1/1/1995 |
| 213 | Date of first routine dialysis. Start: 1/1/1995 |
| 214 | Original date of prescription/orders/referral. Start: 2/28/1997 |
| 215 | Date of tooth extraction/evolution. Start: 1/1/1995 |
| 216 | Drug information. Start: 1/1/1995 |
| 217 | Drug name, strength and dosage form. Start: 1/1/1995 |
| 218 | NDC number. Start: 1/1/1995 |
| 219 | Prescription number. Start: 1/1/1995 |
| 220 | Drug product id number. Start: 1/1/1995 |
| 221 | Drug days supply and dosage. Start: 1/1/1995 |
| 222 | Drug dispensing units and average wholesale price (AWP). Start: 1/1/1995 |
| 223 | Route of drug/myelogram administration. Start: 1/1/1995 |
| 224 | Anatomical location for joint injection. Start: 1/1/1995 |
| 225 | Anatomical location. Start: 1/1/1995 |
| 226 | Joint injection site. Start: 1/1/1995 |
| 227 | Hospital information. Start: 1/1/1995 |
| 228 | Type of bill for UB claim Start: 1/1/1995 | Last Modified: 10/31/2006 |
| 229 | Hospital admission source. Start: 1/1/1995 |
| 230 | Hospital admission hour. Start: 1/1/1995 |
| 231 | Hospital admission type. Start: 1/1/1995 |
| 232 | Admitting diagnosis. Start: 1/1/1995 |
| 233 | Hospital discharge hour. Start: 1/1/1995 |
| 234 | Patient discharge status. Start: 1/1/1995 |
| 235 | Units of blood furnished. Start: 1/1/1995 |
| 236 | Units of blood replaced. Start: 1/1/1995 |
| 237 | Units of deductible blood. Start: 1/1/1995 |
| 238 | Separate claim for mother/baby charges. Start: 1/1/1995 |
| 239 | Dental information. Start: 1/1/1995 |
| 240 | Tooth surface(s) involved. Start: 1/1/1995 |
| 241 | List of all missing teeth (upper and lower). Start: 1/1/1995 |
| 242 | Tooth numbers, surfaces, and/or quadrants involved. Start: 1/1/1995 |
| 243 | Months of dental treatment remaining. Start: 1/1/1995 |
| 244 | Tooth number or letter. Start: 1/1/1995 |
| 245 | Dental quadrant/arch. Start: 1/1/1995 |
| 246 | Total orthodontic service fee, initial appliance fee, monthly fee, length of service. Start: 1/1/1995 |
| 247 | Line information. Start: 1/1/1995 |
| 248 | Accident date, state, description and cause. Start: 1/1/1995 |
| 249 | Place of service. Start: 1/1/1995 |
| 250 | Type of service. Start: 1/1/1995 |
| 251 | Total anesthesia minutes. Start: 1/1/1995 |
| 252 | Authorization/certification number. Start: 1/1/1995 |
| 253 | Procedure/revenue code for service(s) rendered. Use codes 454 or 455. Start: 1/1/1995 | Stop: 2/28/1997 | Last Modified: 7/9/2007 |
| 254 | Primary diagnosis code. Start: 1/1/1995 |
| 255 | Diagnosis code. Start: 1/1/1995 |
| 256 | DRG code(s). Start: 1/1/1995 |
| 257 | ADSM-III-R code for services rendered. Start: 1/1/1995 |
| 258 | Days/units for procedure/revenue code. Start: 1/1/1995 |
| 259 | Frequency of service. Start: 1/1/1995 |
| 260 | Length of medical necessity, including begin date. Start: 2/28/1997 |
| 261 | Obesity measurements. Start: 1/1/1995 |
| 262 | Type of surgery/service for which anesthesia was administered. Start: 1/1/1995 |
| 263 | Length of time for services rendered. Start: 1/1/1995 |
| 264 | Number of liters/minute & total hours/day for respiratory support. Start: 1/1/1995 |
| 265 | Number of lesions excised. Start: 1/1/1995 |
| 266 | Facility point of origin and destination - ambulance. Start: 1/1/1995 |
| 267 | Number of miles patient was transported. Start: 1/1/1995 |
| 268 | Location of durable medical equipment use. Start: 1/1/1995 |
| 269 | Length/size of laceration/tumor. Start: 1/1/1995 |
| 270 | Subluxation location. Start: 1/1/1995 |
| 271 | Number of spine segments. Start: 1/1/1995 |
| 272 | Oxygen contents for oxygen system rental. Start: 1/1/1995 |
| 273 | Weight. Start: 1/1/1995 |
| 274 | Height. Start: 1/1/1995 |
| 275 | Claim. Start: 1/1/1995 |
| 276 | UB04/HCFA-1450/1500 claim form Start: 1/1/1995 | Last Modified: 10/31/2006 |
| 277 | Paper claim. Start: 1/1/1995 |
| 278 | Signed claim form. Start: 1/1/1995 |
| 279 | Itemized claim. Start: 1/1/1995 |
| 280 | Itemized claim by provider. Start: 1/1/1995 |
| 281 | Related confinement claim. Start: 1/1/1995 |
| 282 | Copy of prescription. Start: 1/1/1995 |
| 283 | Medicare worksheet. This change to be effective 7/1/2008: Medicare entitlement information is required to determine primary coverage Start: 1/1/1995 | Last Modified: 1/27/2008 |
| 284 | Copy of Medicare ID card. Start: 1/1/1995 |
| 285 | Vouchers/explanation of benefits (EOB). Start: 1/1/1995 |
| 286 | Other payer's Explanation of Benefits/payment information. Start: 1/1/1995 |
| 287 | Medical necessity for service. Start: 1/1/1995 |
| 288 | Reason for late hospital charges. Start: 1/1/1995 |
| 289 | Reason for late discharge. Start: 1/1/1995 |
| 290 | Pre-existing information. Start: 1/1/1995 |
| 291 | Reason for termination of pregnancy. Start: 1/1/1995 |
| 292 | Purpose of family conference/therapy. Start: 1/1/1995 |
| 293 | Reason for physical therapy. Start: 1/1/1995 |
| 294 | Supporting documentation. Start: 1/1/1995 |
| 295 | Attending physician report. Start: 1/1/1995 |
| 296 | Nurse's notes. Start: 1/1/1995 |
| 297 | Medical notes/report. Start: 2/28/1997 |
| 298 | Operative report. Start: 1/1/1995 |
| 299 | Emergency room notes/report. Start: 1/1/1995 |
| 300 | Lab/test report/notes/results. Start: 2/28/1997 |
| 301 | MRI report. Start: 1/1/1995 |
| 302 | Refer to codes 300 for lab notes and 311 for pathology notes Start: 1/1/1995 | Stop: 1/31/1997 |
| 303 | Physical therapy notes. Use code 297:6O (6 'OH' - not zero) Start: 1/1/1995 | Stop: 2/28/1997 | Last Modified: 7/9/2007 |
| 304 | Reports for service. Start: 1/1/1995 |
| 305 | X-ray reports/interpretation. Start: 1/1/1995 |
| 306 | Detailed description of service. Start: 1/1/1995 |
| 307 | Narrative with pocket depth chart. Start: 1/1/1995 |
| 308 | Discharge summary. Start: 1/1/1995 |
| 309 | Code was duplicate of code 299 Start: 1/1/1995 | Stop: 1/31/1997 |
| 310 | Progress notes for the six months prior to statement date. Start: 1/1/1995 |
| 311 | Pathology notes/report. Start: 1/1/1995 |
| 312 | Dental charting. Start: 1/1/1995 |
| 313 | Bridgework information. Start: 1/1/1995 |
| 314 | Dental records for this service. Start: 1/1/1995 |
| 315 | Past perio treatment history. Start: 1/1/1995 |
| 316 | Complete medical history. Start: 1/1/1995 |
| 317 | Patient's medical records. Start: 1/1/1995 |
| 318 | X-rays. Start: 1/1/1995 |
| 319 | Pre/post-operative x-rays/photographs. Start: 2/28/1997 |
| 320 | Study models. Start: 1/1/1995 |
| 321 | Radiographs or models. Start: 1/1/1995 |
| 322 | Recent fm x-rays. Start: 1/1/1995 |
| 323 | Study models, x-rays, and/or narrative. Start: 1/1/1995 |
| 324 | Recent x-ray of treatment area and/or narrative. Start: 1/1/1995 |
| 325 | Recent fm x-rays and/or narrative. Start: 1/1/1995 |
| 326 | Copy of transplant acquisition invoice. Start: 1/1/1995 |
| 327 | Periodontal case type diagnosis and recent pocket depth chart with narrative. Start: 1/1/1995 |
| 328 | Speech therapy notes. Use code 297:6R Start: 1/1/1995 | Stop: 2/28/1997 | Last Modified: 7/9/2007 |
| 329 | Exercise notes. Start: 1/1/1995 |
| 330 | Occupational notes. Start: 1/1/1995 |
| 331 | History and physical. Start: 1/1/1995 | Last Modified: 8/1/2007 |
| 332 | Authorization/certification (include period covered). (Use code 252) Start: 2/28/1997 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 333 | Patient release of information authorization. Start: 1/1/1995 |
| 334 | Oxygen certification. Start: 1/1/1995 |
| 335 | Durable medical equipment certification. Start: 1/1/1995 |
| 336 | Chiropractic certification. Start: 1/1/1995 |
| 337 | Ambulance certification/documentation. Start: 1/1/1995 |
| 338 | Home health certification. Use code 332:4Y Start: 1/1/1995 | Stop: 2/28/1997 | Last Modified: 7/9/2007 |
| 339 | Enteral/parenteral certification. Start: 1/1/1995 |
| 340 | Pacemaker certification. Start: 1/1/1995 |
| 341 | Private duty nursing certification. Start: 1/1/1995 |
| 342 | Podiatric certification. Start: 1/1/1995 |
| 343 | Documentation that facility is state licensed and Medicare approved as a surgical facility. Start: 1/1/1995 |
| 344 | Documentation that provider of physical therapy is Medicare Part B approved. Start: 1/1/1995 |
| 345 | Treatment plan for service/diagnosis Start: 1/1/1995 |
| 346 | Proposed treatment plan for next 6 months. Start: 1/1/1995 |
| 347 | Refer to code 345 for treatment plan and code 282 for prescription Start: 1/1/1995 | Stop: 1/31/1997 |
| 348 | Chiropractic treatment plan. (Use 345:QL) Start: 1/1/1995 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 349 | Psychiatric treatment plan. Use codes 345:5I, 5J, 5K, 5L, 5M, 5N, 5O (5 'OH' - not zero), 5P Start: 1/1/1995 | Stop: 2/28/1997 | Last Modified: 7/9/2007 |
| 350 | Speech pathology treatment plan. Use code 345:6R Start: 1/1/1995 | Stop: 2/28/1997 | Last Modified: 7/9/2007 |
| 351 | Physical/occupational therapy treatment plan. Use codes 345:6O (6 'OH' - not zero), 6N Start: 1/1/1995 | Stop: 2/28/1997 | Last Modified: 7/9/2007 |
| 352 | Duration of treatment plan. Start: 1/1/1995 |
| 353 | Orthodontics treatment plan. Start: 1/1/1995 |
| 354 | Treatment plan for replacement of remaining missing teeth. Start: 1/1/1995 |
| 355 | Has claim been paid? Start: 1/1/1995 |
| 356 | Was blood furnished? Start: 1/1/1995 |
| 357 | Has or will blood be replaced? Start: 1/1/1995 |
| 358 | Does provider accept assignment of benefits? Start: 1/1/1995 |
| 359 | Is there a release of information signature on file? Start: 1/1/1995 |
| 360 | Is there an assignment of benefits signature on file? Start: 1/1/1995 |
| 361 | Is there other insurance? Start: 1/1/1995 |
| 362 | Is the dental patient covered by medical insurance? Start: 1/1/1995 |
| 363 | Will worker's compensation cover submitted charges? Start: 1/1/1995 |
| 364 | Is accident/illness/condition employment related? Start: 1/1/1995 |
| 365 | Is service the result of an accident? Start: 1/1/1995 |
| 366 | Is injury due to auto accident? Start: 1/1/1995 |
| 367 | Is service performed for a recurring condition or new condition? Start: 1/1/1995 |
| 368 | Is medical doctor (MD) or doctor of osteopath (DO) on staff of this facility? Start: 1/1/1995 |
| 369 | Does patient condition preclude use of ordinary bed? Start: 1/1/1995 |
| 370 | Can patient operate controls of bed? Start: 1/1/1995 |
| 371 | Is patient confined to room? Start: 1/1/1995 |
| 372 | Is patient confined to bed? Start: 1/1/1995 |
| 373 | Is patient an insulin diabetic? Start: 1/1/1995 |
| 374 | Is prescribed lenses a result of cataract surgery? Start: 1/1/1995 |
| 375 | Was refraction performed? Start: 1/1/1995 |
| 376 | Was charge for ambulance for a round-trip? Start: 1/1/1995 |
| 377 | Was durable medical equipment purchased new or used? Start: 1/1/1995 |
| 378 | Is pacemaker temporary or permanent? Start: 1/1/1995 |
| 379 | Were services performed supervised by a physician? Start: 1/1/1995 |
| 380 | Were services performed by a CRNA under appropriate medical direction? Start: 1/1/1995 | Last Modified: 10/31/1999 |
| 381 | Is drug generic? Start: 1/1/1995 |
| 382 | Did provider authorize generic or brand name dispensing? Start: 1/1/1995 |
| 383 | Was nerve block used for surgical procedure or pain management? Start: 1/1/1995 |
| 384 | Is prosthesis/crown/inlay placement an initial placement or a replacement? Start: 1/1/1995 |
| 385 | Is appliance upper or lower arch & is appliance fixed or removable? Start: 1/1/1995 |
| 386 | Is service for orthodontic purposes? Start: 1/1/1995 |
| 387 | Date patient last examined by entity Start: 2/28/1997 |
| 388 | Date post-operative care assumed Start: 2/28/1997 |
| 389 | Date post-operative care relinquished Start: 2/28/1997 |
| 390 | Date of most recent medical event necessitating service(s) Start: 2/28/1997 |
| 391 | Date(s) dialysis conducted Start: 2/28/1997 |
| 392 | Date(s) of blood transfusion(s) Start: 2/28/1997 |
| 393 | Date of previous pacemaker check Start: 2/28/1997 |
| 394 | Date(s) of most recent hospitalization related to service Start: 2/28/1997 |
| 395 | Date entity signed certification/recertification Start: 2/28/1997 |
| 396 | Date home dialysis began Start: 2/28/1997 |
| 397 | Date of onset/exacerbation of illness/condition Start: 2/28/1997 |
| 398 | Visual field test results Start: 2/28/1997 |
| 399 | Report of prior testing related to this service, including dates Start: 2/28/1997 |
| 400 | Claim is out of balance Start: 2/28/1997 |
| 401 | Source of payment is not valid Start: 2/28/1997 |
| 402 | Amount must be greater than zero Start: 2/28/1997 |
| 403 | Entity referral notes/orders/prescription Start: 2/28/1997 |
| 404 | Specific findings, complaints, or symptoms necessitating service Start: 2/28/1997 |
| 405 | Summary of services Start: 2/28/1997 |
| 406 | Brief medical history as related to service(s) Start: 2/28/1997 |
| 407 | Complications/mitigating circumstances Start: 2/28/1997 |
| 408 | Initial certification Start: 2/28/1997 |
| 409 | Medication logs/records (including medication therapy) Start: 2/28/1997 |
| 410 | Explain differences between treatment plan and patient's condition Start: 2/28/1997 |
| 411 | Medical necessity for non-routine service(s) Start: 2/28/1997 |
| 412 | Medical records to substantiate decision of non-coverage Start: 2/28/1997 |
| 413 | Explain/justify differences between treatment plan and services rendered. Start: 2/28/1997 |
| 414 | Need for more than one physician to treat patient Start: 2/28/1997 |
| 415 | Justify services outside composite rate Start: 2/28/1997 |
| 416 | Verification of patient's ability to retain and use information Start: 2/28/1997 |
| 417 | Prior testing, including result(s) and date(s) as related to service(s) Start: 2/28/1997 |
| 418 | Indicating why medications cannot be taken orally Start: 2/28/1997 |
| 419 | Individual test(s) comprising the panel and the charges for each test Start: 2/28/1997 |
| 420 | Name, dosage and medical justification of contrast material used for radiology procedure Start: 2/28/1997 |
| 421 | Medical review attachment/information for service(s) Start: 2/28/1997 |
| 422 | Homebound status Start: 2/28/1997 |
| 423 | Prognosis Start: 2/28/1997 | Stop: 1/1/2008 | Last Modified: 7/9/2007 |
| 424 | Statement of non-coverage including itemized bill Start: 2/28/1997 |
| 425 | Itemize non-covered services Start: 2/28/1997 |
| 426 | All current diagnoses Start: 2/28/1997 |
| 427 | Emergency care provided during transport Start: 2/28/1997 |
| 428 | Reason for transport by ambulance Start: 2/28/1997 |
| 429 | Loaded miles and charges for transport to nearest facility with appropriate services Start: 2/28/1997 |
| 430 | Nearest appropriate facility Start: 2/28/1997 |
| 431 | Provide condition/functional status at time of service Start: 2/28/1997 |
| 432 | Date benefits exhausted Start: 2/28/1997 |
| 433 | Copy of patient revocation of hospice benefits Start: 2/28/1997 |
| 434 | Reasons for more than one transfer per entitlement period Start: 2/28/1997 |
| 435 | Notice of Admission Start: 2/28/1997 |
| 436 | Short term goals Start: 2/28/1997 |
| 437 | Long term goals Start: 2/28/1997 |
| 438 | Number of patients attending session Start: 2/28/1997 |
| 439 | Size, depth, amount, and type of drainage wounds Start: 2/28/1997 |
| 440 | why non-skilled caregiver has not been taught procedure Start: 2/28/1997 |
| 441 | Entity professional qualification for service(s) Start: 2/28/1997 |
| 442 | Modalities of service Start: 2/28/1997 |
| 443 | Initial evaluation report Start: 2/28/1997 |
| 444 | Method used to obtain test sample Start: 2/28/1997 |
| 445 | Explain why hearing loss not correctable by hearing aid Start: 2/28/1997 |
| 446 | Documentation from prior claim(s) related to service(s) Start: 2/28/1997 |
| 447 | Plan of teaching Start: 2/28/1997 |
| 448 | Invalid billing combination. See STC12 for details. This code should only be used to indicate an inconsistency between two or more data elements on the claim. A detailed explanation is required in STC12 when this code is used. Start: 2/28/1997 |
| 449 | Projected date to discontinue service(s) Start: 2/28/1997 |
| 450 | Awaiting spend down determination Start: 2/28/1997 |
| 451 | Preoperative and post-operative diagnosis Start: 2/28/1997 |
| 452 | Total visits in total number of hours/day and total number of hours/week Start: 2/28/1997 |
| 453 | Procedure Code Modifier(s) for Service(s) Rendered Start: 2/28/1997 |
| 454 | Procedure code for services rendered. Start: 2/28/1997 |
| 455 | Revenue code for services rendered. Start: 2/28/1997 |
| 456 | Covered Day(s) Start: 2/28/1997 |
| 457 | Non-Covered Day(s) Start: 2/28/1997 |
| 458 | Coinsurance Day(s) Start: 2/28/1997 |
| 459 | Lifetime Reserve Day(s) Start: 2/28/1997 |
| 460 | NUBC Condition Code(s) Start: 2/28/1997 |
| 461 | NUBC Occurrence Code(s) and Date(s) Start: 2/28/1997 |
| 462 | NUBC Occurrence Span Code(s) and Date(s) Start: 2/28/1997 |
| 463 | NUBC Value Code(s) and/or Amount(s) Start: 2/28/1997 |
| 464 | Payer Assigned Claim Control Number Start: 2/28/1997 | Last Modified: 10/31/2004 |
| 465 | Principal Procedure Code for Service(s) Rendered Start: 2/28/1997 |
| 466 | Entities Original Signature Start: 2/28/1997 |
| 467 | Entity Signature Date Start: 2/28/1997 |
| 468 | Patient Signature Source Start: 2/28/1997 |
| 469 | Purchase Service Charge Start: 2/28/1997 |
| 470 | Was service purchased from another entity? Start: 2/28/1997 |
| 471 | Were services related to an emergency? Start: 2/28/1997 |
| 472 | Ambulance Run Sheet Start: 2/28/1997 |
| 473 | Missing or invalid lab indicator Start: 6/30/1998 |
| 474 | Procedure code and patient gender mismatch Start: 6/30/1998 | Last Modified: 2/29/2000 |
| 475 | Procedure code not valid for patient age Start: 6/30/1998 | Last Modified: 2/29/2000 |
| 476 | Missing or invalid units of service Start: 6/30/1998 |
| 477 | Diagnosis code pointer is missing or invalid Start: 6/30/1998 |
| 478 | Claim submitter's identifier (patient account number) is missing Start: 6/30/1998 |
| 479 | Other Carrier payer ID is missing or invalid Start: 6/30/1998 |
| 480 | Other Carrier Claim filing indicator is missing or invalid Start: 6/30/1998 |
| 481 | Claim/submission format is invalid. Start: 10/31/1998 |
| 482 | Date Error, Century Missing Start: 2/28/1999 |
| 483 | Maximum coverage amount met or exceeded for benefit period. Start: 6/30/1999 |
| 484 | Business Application Currently Not Available Start: 2/29/2000 |
| 485 | More information available than can be returned in real time mode. Narrow your current search criteria. Start: 2/28/2001 |
| 486 | Principle Procedure Date Start: 10/31/2001 |
| 487 | Claim not found, claim should have been submitted to/through 'entity' Start: 2/28/2002 |
| 488 | Diagnosis code(s) for the services rendered. Start: 6/30/2002 |
| 489 | Attachment Control Number Start: 10/31/2002 |
| 490 | Other Procedure Code for Service(s) Rendered Start: 2/28/2003 |
| 491 | Entity not eligible for encounter submission Start: 2/28/2003 |
| 492 | Other Procedure Date Start: 2/28/2003 |
| 493 | Version/Release/Industry ID code not currently supported by information holder Start: 2/28/2003 |
| 494 | Real-Time requests not supported by the information holder, resubmit as batch request Start: 2/28/2003 |
| 495 | Requests for re-adjudication must reference the newly assigned payer claim control number for this previously adjusted claim. Correct the payer claim control number and re-submit. Start: 10/31/2003 |
| 496 | Submitter not approved for electronic claim submissions on behalf of this entity Start: 2/29/2004 |
| 497 | Sales tax not paid Start: 6/30/2004 |
| 498 | Maximum leave days exhausted Start: 6/30/2004 |
| 499 | No rate on file with the payer for this service for this entity Start: 6/30/2004 |
| 500 | Entity's Postal/Zip Code Start: 6/30/2004 |
| 501 | Entity's State/Province Start: 6/30/2004 |
| 502 | Entity's City Start: 6/30/2004 |
| 503 | Entity's Street Address Start: 6/30/2004 |
| 504 | Entity's Last Name Start: 6/30/2004 |
| 505 | Entity's First Name Start: 6/30/2004 |
| 506 | Entity is changing processor/clearinghouse. This claim must be submitted to the new processor/clearinghouse Start: 6/30/2004 |
| 507 | HCPCS Start: 10/31/2004 |
| 508 | ICD9 Start: 10/31/2004 |
| 509 | E-Code Start: 10/31/2004 |
| 510 | Future date Start: 10/31/2004 |
| 511 | Invalid character Start: 10/31/2004 |
| 512 | Length invalid for receiver's application system Start: 10/31/2004 |
| 513 | HIPPS Rate Code for services Rendered Start: 10/31/2004 |
| 514 | Entities Middle Name Start: 10/31/2004 |
| 515 | Managed Care review Start: 10/31/2004 |
| 516 | Adjudication or Payment Date Start: 10/31/2004 |
| 517 | Adjusted Repriced Claim Reference Number Start: 10/31/2004 |
| 518 | Adjusted Repriced Line item Reference Number Start: 10/31/2004 |
| 519 | Adjustment Amount Start: 10/31/2004 |
| 520 | Adjustment Quantity Start: 10/31/2004 |
| 521 | Adjustment Reason Code Start: 10/31/2004 |
| 522 | Anesthesia Modifying Units Start: 10/31/2004 |
| 523 | Anesthesia Unit Count Start: 10/31/2004 |
| 524 | Arterial Blood Gas Quantity Start: 10/31/2004 |
| 525 | Begin Therapy Date Start: 10/31/2004 |
| 526 | Bundled or Unbund |