Claims code lists

You may need to reference the following code lists when submitting professional, dental, and institutional claims and receiving claim remittances (ERAs) through the Stedi clearinghouse. Note that this page doesn’t contain every code list in the claim specifications; it only contains code lists that are too long to represent clearly within the API reference documentation.

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Adjustment Reason Codes

Returned in the 835 ERA Report transactions.providerAdjustments.adjustments.adjustmentReasonCode property.

• 50 - Late Charge | This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty.
• 51 - Interest Penalty Charge | This is the interest assessment for late filing.
• 72 - Authorized Return | This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment.
• 90 - Early Payment Allowance
• AH - Origination Fee | This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims.
• AM - Applied to Borrower’s Account | This code identifies the loan repayment amount. This is capitation specific.
• AP - Acceleration of Benefits | This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in providerAdjustmentAmount. A positive value represents a withholding. A negative value represents a payment.
• B2 - Rebate | This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess is reported as a negative amount using this code, returning the excess funds to the provider.
• B3 - Recovery Allowance | This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72.
• BD - Bad Debt Adjustment | This is the bad debt passthrough.
• BN - Bonus | This is capitation specific.
• C5 - Temporary Allowance | This is the tentative adjustment.
• CR - Capitation Interest | This is capitation specific.
• CS - Adjustment | The payer should provide supporting information in providerAdjustmentIdentifier.
• CT - Capitation Payment | This is capitation specific.
• CV - Capital Passthru
• CW - Certified Registered Nurse Anesthetist Passthru
• DM - Direct Medical Education Passthru
• E3 - Withholding
• FB - Forwarding Balance | This is the balance forward. A negative value in providerAdjustmentAmount represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. The payer should also supply a reference number in providerAdjustmentIdentifier for tracking purposes.
• FC - Fund Allocation | This is capitation specific. The payer should list the specific fund in providerAdjustmentIdentifier.
• GO - Graduate Medical Education Passthru
• HM - Hemophilia Clotting Factor Supplement
• IP - Incentive Premium Payment | This is capitation specific.
• IR - Internal Revenue Service Withholding
• IS - Interim Settlement | This is the interim rate lump sum adjustment.
• J1 - Nonreimbursable | This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment.
• L3 - Penalty | This is the capitation-related penalty. Withholding or release is identified by the sign in providerAdjustmentAmount.
• L6 - Interest Owed | This is the interest paid on claims in this 835.
• LE - Levy | IRS Levy
• LS - Lump Sum | This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The payer should identify the specific type of lump sum adjustment in providerAdjustmentIdentifier.
• OA - Organ Acquisition Passthru
• OB - Offset for Affiliated Providers | The payer should identify affiliated providers in providerAdjustmentIdentifier.
• PI - Periodic Interim Payment | This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in providerAdjustmentAmount determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment.
• PL - Payment Final | This is the final settlement.
• RA - Retro-activity Adjustment | This is capitation specific.
• RE - Return on Equity
• SL - Student Loan Repayment
• TL - Third Party Liability | This is capitation specific.
• WO - Overpayment Recovery | This is the recovery of previous overpayment. The payer should provide an identifying number in providerAdjustmentIdentifier.
• WU - Unspecified Recovery | Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source).

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Ambulance Certification Condition Codes

Used in the Professional Claims claimInformation.ambulanceCertification.conditionCodes property.

• 01 - Patient was admitted to a hospital
• 04 - Patient was moved by stretcher
• 05 - Patient was unconscious or in shock
• 06 - Patient was transported in an emergency situation
• 07 - Patient had to be physically restrained
• 08 - Patient had visible hemorrhaging
• 09 - Ambulance service was medically necessary
• 12 - Patient is confined to a bed or chair; use to indicate that the patient was bedridden during transport

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Ambulance Transport Reason Codes

Used in the Professional Claims claimInformation.ambulanceTransportInformation.ambulanceTransportReasonCode property.

• A - Patient was transported to nearest facility for care of symptoms, complaints, or both
• B - Patient was transported for the benefit of a preferred physician
• C - Patient was transported for the nearness of family members
• D - Patient was transported for the care of a specialist or for availability of specialized equipment
• E - Patient Transferred to Rehabilitation Facility

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Attachment Report Type Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.serviceLines.serviceLineSupplementalInformation.attachmentReportTypeCode property
• Institutional Claims claimInformation.claimSupplementalInformation.reportInformation.attachmentReportTypeCode property
• Dental Claims claimInformation.claimSupplementalInformation.reportInformation.attachmentReportTypeCode property. A subset of the codes are supported for dental claims.

You can use the following codes:

• 03 - Report Justifying Treatment Beyond Utilization Guidelines
• 04 - Drugs Administered
• 05 - Treatment Diagnosis
• 06 - Initial Assessment
• 07 - Functional Goals
• 08 - Plan of Treatment
• 09 - Progress Report
• 10 - Continued Treatment
• 11 - Chemical Analysis
• 13 - Certified Test Report
• 15 - Justification for Admission
• 21 - Recovery Plan
• A3 - Allergies/Sensitivities Document
• A4 - Autopsy Report
• AM - Ambulance Certification
• AS - Admission Summary
• B2 - Prescription
• B3 - Physician Order
• B4 - Referral Form
• BR - Benchmark Testing Results
• BS - Baseline
• BT - Blanket Test Results
• CB - Chiropractic Justification
• CK - Consent Form(s)
• CT - Certification
• D2 - Drug Profile Document
• DA - Dental Models
• DB - Durable Medical Equipment Prescription
• DG - Diagnostic Report
• DJ - Discharge Monitoring Report
• DS - Discharge Summary
• EB - Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
• HC - Health Certificate
• HR - Health Clinic Records
• I5 - Immunization Record
• IR - State School Immunization Records
• LA - Laboratory Results
• M1 - Medical Record Attachment
• MT - Models
• NN - Nursing Notes
• OB - Operative Note
• OC - Oxygen Content Averaging Report
• OD - Orders and Treatments Document
• OE - Objective Physical Examination (including vital signs) Document
• OX - Oxygen Therapy Certification
• OZ - Support Data for Claim
• P4 - Pathology Report
• P5 - Patient Medical History Document
• PE - Parenteral or Enteral Certification
• PN - Physical Therapy Notes
• PO - Prosthetics or Orthotic Certification
• PQ - Paramedical Results
• PY - Physician’s Report
• PZ - Physical Therapy Certification
• RB - Radiology Films
• RR - Radiology Reports
• RT - Report of Tests and Analysis Report
• RX - Renewable Oxygen Content Averaging Report
• SG - Symptoms Document
• V5 - Death Notification
• XP - Photographs

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Dental

For dental claims, only the following attachment report type codes are supported:

• B4 - Referral Form
• DA - Dental Models
• DG - Diagnostic Report
• EB - Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
• OZ - Support Data for Claim
• P6 - Periodontal Charts
• RB - Radiology Films
• RR - Radiology Reports

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Attachment Transmission Codes

Used in the Professional Claims claimInformation.serviceLines.durableMedicalEquipmentCertificateOfMedicalNecessity.attachmentTransmissionCode property.

• AB - Previously Submitted to Payer
• AD - Certification Included in this Claim
• AF - Narrative Segment Included in this Claim
• AG - No Documentation is Required
• NS - Not Specified; Paperwork is available on request at the provider’s site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

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Claim Filing Indicator Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.claimFilingCode and claimInformation.otherSubscriberInformation.claimFilingIndicatorCode properties.
• Institutional Claims claimInformation.claimFilingCode and claimInformation.otherSubscriberInformation.claimFilingIndicatorCode properties.
• Dental Claims claimInformation.claimFilingCode and claimInformation.otherSubscriberInformation.claimFilingIndicatorCode properties.

You can use the following codes:

• 11 - Other Non-Federal Programs
• 12 - Preferred Provider Organization (PPO)
• 13 - Point of Service (POS)
• 14 - Exclusive Provider Organization (EPO)
• 15 - Indemnity Insurance
• 16 - Health Maintenance Organization (HMO) Medicare Risk
• 17 - Dental Maintenance Organization
• AM - Automobile Medical
• BL - Blue Cross/Blue Shield
• CH - Champus
• CI - Commercial Insurance Co.
• DS - Disability
• FI - Federal Employees Program
• HM - Health Maintenance Organization
• LM - Liability Medical
• MA - Medicare Part A
• MB - Medicare Part B
• MC - Medicaid
• OF - Other Federal Program; Use when submitting Medicare Part D claims
• TV - Title V
• VA - Veterans Affairs Plan
• WC - Workers’ Compensation Health Claim
• ZZ - Mutually Defined; Use when Type of Insurance is not known

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Claim Pricing (Institutional Claims)

For properties in the Institutional Claims claimInformation.claimPricingInformation object and the claimInformation.serviceLines.lineAdjudicationInformation object.

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Exception Codes

Used in the Institutional Claims claimInformation.claimPricingInformation.exceptionCode property.

• 1 - Non-Network Professional Provider in Network Hospital
• 2 - Emergency Care
• 3 - Services or Specialist not in Network
• 4 - Out-of-Service Area
• 5 - State Mandates
• 6 - Other

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Policy Compliance Codes

Used in the Institutional Claims claimInformation.claimPricingInformation.policyComplianceCode and claimInformation.serviceLines.linePricingInformation.policyComplianceCode properties.

• 1 - Procedure Followed (Compliance)
• 2 - Not Followed - Call Not Made (Non-Compliance Call Not Made)
• 3 - Not Medically Necessary (Non-Compliance Non-Medically Necessary)
• 4 - Not Followed Other (Non-Compliance Other)
• 5 - Emergency Admit to Non-Network Hospital

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Pricing Methodology Codes

Used in the Institutional Claims claimInformation.claimPricingInformation.pricingMethodologyCode and claimInformation.serviceLines.lineRepricingInformation.pricingMethodologyCode properties.

• 00 - Zero Pricing (Not Covered Under Contract)
• 01 - Priced as Billed at 100%
• 02 - Priced at the Standard Fee Schedule
• 03 - Priced at a Contractual Percentage
• 04 - Bundled Pricing
• 05 - Peer Review Pricing
• 06 - Per Diem Pricing
• 07 - Flat Rate Pricing
• 08 - Combination Pricing
• 09 - Maternity Pricing
• 10 - Other Pricing
• 11 - Lower of Cost
• 12 - Ratio of Cost
• 13 - Cost Reimbursed
• 14 - Adjustment Pricing

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Product or Service ID Qualifier Codes

Used in the Institutional Claims properties:

• claimInformation.claimPricingInformation.productOrServiceIDQualifier

• claimInformation.serviceLines.lineAdjudicationInformation.productOrServiceIDQualifier

• claimInformation.serviceLines.institutionalService.procedureIdentifier

• claimInformation.serviceLines.lineRepricingInformation.productOrServiceIDQualifier

• ER - Jurisdiction Specific Procedure and Supply Codes; Not allowed for use under HIPAA. You can only use this code if a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR the Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR for claims not covered by HIPAA.

• HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes; Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported under HC.

• HP - Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

• IV - Home Infusion EDI Coalition (HIEC) Product/Service Code; Not allowed for use under HIPAA. You can only use this qualifier if a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR the Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR for claims not covered by HIPAA.

• WK - Advanced Billing Concepts (ABC) Codes; Approved by the Secretary of HHS as a pilot project allowed under HIPAA law. Only parties registered in the pilot project and their trading partners can use this qualifier in transactions covered by HIPAA. Otherwise, you can only use this code if a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA OR for claims not covered by HIPAA.

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Reject Reason Codes

Used in the Institutional Claims claimInformation.claimPricingInformation.rejectReasonCode and claimInformation.serviceLines.lineRepricingInformation.rejectReasonCode properties.

• T1 - Cannot Identify Provider as TPO (Third Party Organization) Participant
• T2 - Cannot Identify Payer as TPO (Third Party Organization) Participant
• T3 - Cannot Identify Insured as TPO (Third Party Organization) Participant
• T4 - Payer Name or Identifier Missing
• T5 - Certification Information Missing
• T6 - Claim does not contain enough information for re-pricing

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Composite Medical Procedure - Product or Service ID Qualifier Codes

Used in the Professional Claims claimInformation.serviceLines.lineAdjudicationInformation.serviceIdQualifier and claimInformation.serviceLines.professionalService.procedureIdentifier properties.

• ER - Jurisdiction Specific Procedure and Supply Codes; Not allowed for use under HIPAA. You can only use this code if a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR the Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR for claims not covered by HIPAA.
• HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes; Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported under HC.
• IV - Home Infusion EDI Coalition (HIEC) Product/Service Code; Not allowed for use under HIPAA. You can only use this qualifier if a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR the Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR for claims not covered by HIPAA.
• WK - Advanced Billing Concepts (ABC) Codes; Approved by the Secretary of HHS as a pilot project allowed under HIPAA law. Only parties registered in the pilot project and their trading partners can use this qualifier in transactions covered by HIPAA. Otherwise, you can only use this code if a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA OR for claims not covered by HIPAA.

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Delay Reason Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.delayReasonCode property.
• Institutional Claims claimInformation.delayReasonCode property.
• Dental Claims claimInformation.delayReasonCode property.

You can use the following codes:

• 1 - Proof of Eligibility Unknown or Unavailable
• 2 - Litigation
• 3 - Authorization Delays
• 4 - Delay in Certifying Provider
• 5 - Delay in Supplying Billing Forms
• 6 - Delay in Delivery of Custom-made Appliances
• 7 - Third Party Processing Delay
• 8 - Delay in Eligibility Determination
• 9 - Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
• 10 - Administration Delay in the Prior Approval Process
• 11 - Other
• 15 - Natural Disaster

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Drug Identification Product or Service ID Qualifier Codes

Used in the Professional Claims claimInformation.serviceLines.drugIdentification.serviceIdQualifier property.

• EN - EAN/UCC - 13
• EO - EAN/UCC - 8
• HI - HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message
• N4 - National Drug Code in 5-4-2 Format
• ON - Customer Order Number
• UK - GTIN 14-digit Data Structure
• UP - UCC - 12

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Individual Relationship Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.otherSubscriberInformation.individualRelationshipCode property.
• Institutional Claims claimInformation.otherSubscriberInformation.individualRelationshipCode property.
• Dental Claims claimInformation.otherSubscriberInformation.individualRelationshipCode property.

You can use the following codes:

• 01 - Spouse
• 18 - Self
• 19 - Child
• 20 - Employee
• 21 - Unknown
• 39 - Organ Donor
• 40 - Cadaver Donor
• 53 - Life Partner
• G8 - Other Relationship

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Insurance Type Codes

Used in the following APIs and properties:

• Professional Claims subscriber.insuranceTypeCode and claimInformation.otherSubscriberInformation.insuranceTypeCode properties.
• Dental Claims subscriber.insuranceTypeCode and claimInformation.otherSubscriberInformation.insuranceTypeCode properties.

You can use the following codes:

• 12 - Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
• 13 - Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan
• 14 - Medicare Secondary, No-fault Insurance including Auto is Primary
• 15 - Medicare Secondary Worker’s Compensation
• 16 - Medicare Secondary Public Health Service (PHS)or Other Federal Agency
• 41 - Medicare Secondary Black Lung
• 42 - Medicare Secondary Veteran’s Administration
• 43 - Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
• 47 - Medicare Secondary, Other Liability Insurance is Primary

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Payment Responsibility Sequence Number Codes

Used in the following APIs and properties:

• Professional Claims subscriber.paymentResponsibilityLevelCode and claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode properties.
• Institutional Claims claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode property.
• Dental Claims subscriber.paymentResponsibilityLevelCode and claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode properties.

You can use the following codes:

• A - Payer Responsibility Four
• B - Payer Responsibility Five
• C - Payer Responsibility Six
• D - Payer Responsibility Seven
• E - Payer Responsibility Eight
• F - Payer Responsibility Nine
• G - Payer Responsibility Ten
• H - Payer Responsibility Eleven
• P - Primary
• S - Secondary
• T - Tertiary
• U - Unknown; This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

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Pricing/Repricing (Professional and Dental Claims)

Used in the Professional Claims and Dental Claims APIs.

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Exception Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.claimPricingRepricingInformation.exceptionCode and claimInformation.serviceLines.linePricingRepricingInformation.exceptionCode properties.
• Dental Claims claimInformation.claimPricingRepricingInformation.exceptionCode and claimInformation.serviceLines.linePricingRepricingInformation.exceptionCode properties.

You can use the following codes:

• 1 - Non-Network Professional Provider in Network Hospital
• 2 - Emergency Care
• 3 - Services or Specialist not in Network
• 4 - Out-of-Service Area
• 5 - State Mandates
• 6 - Other

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Policy Compliance Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.claimPricingRepricingInformation.policyComplianceCode and claimInformation.serviceLines.linePricingRepricingInformation.policyComplianceCode properties.
• Dental Claims claimInformation.claimPricingRepricingInformation.policyComplianceCode and claimInformation.serviceLines.linePricingRepricingInformation.policyComplianceCode properties.

You can use the following codes:

• 1 - Procedure Followed (Compliance)
• 2 - Not Followed - Call Not Made (Non-Compliance Call Not Made)
• 3 - Not Medically Necessary (Non-Compliance Non-Medically Necessary)
• 4 - Not Followed Other (Non-Compliance Other)
• 5 - Emergency Admit to Non-Network Hospital

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Pricing Methodology Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.claimPricingRepricingInformation.pricingMethodologyCode and claimInformation.serviceLines.linePricingRepricingInformation.pricingMethodologyCode properties.
• Dental Claims claimInformation.claimPricingRepricingInformation.pricingMethodologyCode and claimInformation.serviceLines.linePricingRepricingInformation.pricingMethodologyCode properties.

You can use the following codes:

• 00 - Zero Pricing (Not Covered Under Contract)
• 01 - Priced as Billed at 100%
• 02 - Priced at the Standard Fee Schedule
• 03 - Priced at a Contractual Percentage
• 04 - Bundled Pricing
• 05 - Peer Review Pricing
• 07 - Flat Rate Pricing
• 08 - Combination Pricing
• 09 - Maternity Pricing
• 10 - Other Pricing
• 11 - Lower of Cost
• 12 - Ratio of Cost
• 13 - Cost Reimbursed
• 14 - Adjustment Pricing

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Reject Reason Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.claimPricingRepricingInformation.rejectReasonCode and claimInformation.serviceLines.linePricingRepricingInformation.rejectReasonCode properties.
• Dental Claims claimInformation.claimPricingRepricingInformation.rejectReasonCode and claimInformation.serviceLines.linePricingRepricingInformation.rejectReasonCode properties.

You can use the following codes:

• T1 - Cannot Identify Provider as TPO (Third Party Organization) Participant
• T2 - Cannot Identify Payer as TPO (Third Party Organization) Participant
• T3 - Cannot Identify Insured as TPO (Third Party Organization) Participant
• T4 - Payer Name or Identifier Missing
• T5 - Certification Information Missing
• T6 - Claim does not contain enough information for re-pricing

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Service Authorization Exception Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode property
• Institutional Claims claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode property.
• Dental Claims claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode property

You can use the following codes:

• 1 - Immediate/Urgent Care
• 2 - Services Rendered in a Retroactive Period
• 3 - Emergency Care
• 4 - Client has Temporary Medicaid
• 5 - Request from County for Second Opinion to Determine if Recipient Can Work
• 6 - Request for Override Pending
• 7 - Special Handling

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Vision Condition Codes

Used in the Professional Claims claimInformation.patientConditionInformationVision.conditionCodes property.

• L1 - General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
• L2 - Replacement Due to Loss or Theft
• L3 - Replacement Due to Breakage or Damage
• L4 - Replacement Due to Patient Preference
• L5 - Replacement Due to Medical Reason