Claim Adjustment Reason Codes - Palmetto GBA

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ReasonCodesM20M21M22M23M24M25DescriptionMissing/incomplete/invalid HCPCS.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid place of residence for this service/itemprovided in a home.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of miles traveled.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing invoice.Start: 01/01/1997 | Last Modified: 08/01/2005Notes: (Modified 8/1/05)Missing/incomplete/invalid number of doses per vial.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)The information furnished does not substantiate the need for this levelof service. If you believe the service should have been fully covered asbilled, or if you did not know and could not reasonably have beenexpected to know that we would not pay for this level of service, or ifyou notified the patient in writing in advance that we would not pay forthis level of service and he/she agreed in writing to pay, ask us toreview your claim within 120 days of the date of this notice. If you do notrequest a appeal, we will, upon application from the patient, reimbursehim/her for the amount you have collected from him/her in excess ofany deductible and coinsurance amounts. We will recover thereimbursement from you as an overpayment.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07)4
ReasonCodesM26DescriptionThe information furnished does not substantiate the need for this levelof service. If you have collected any amount from the patient for thislevel of service /any amount that exceeds the limiting charge for the lessextensive service, the law requires you to refund that amount to thepatient within 30 days of receiving this notice.M27M28The requirements for refund are in 1824(I) of the Social Security Act and42CFR411.408. The section specifies that physicians who knowinglyand willfully fail to make appropriate refunds may be subject to civilmonetary penalties and/or exclusion from the program. If you have anyquestions about this notice, please contact this office.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07. Also refer to N356)Alert: The patient has been relieved of liability of payment of these itemsand services under the limitation of liability provision of the law. Theprovider is ultimately liable for the patient's waived charges, includingany charges for coinsurance, since the items or services were notreasonable and necessary or constituted custodial care, and you knewor could reasonably have been expected to know, that they were notcovered. You may appeal this determination. You may ask for an appealregarding both the coverage determination and the issue of whether youexercised due care. The appeal request must be filed within 120 days ofthe date you receive this notice. You must make the request throughthis office.Start: 01/01/1997 | Last Modified: 08/01/2007Notes: (Modified 10/1/02, 8/1/05, 4/1/07, 8/1/07)This does not qualify for payment under Part B when Part A coverage isexhausted or not otherwise available.Start: 01/01/19975
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Claim Adjustment Reason Codes - Palmetto GBA

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