Claims Processing Error Code Listing

Department of Healthcare and Family Services

Division of Medical Programs
Published: November 2016

Error
Message
Code

A04 Date Paid Missing/Invalid

Payee Code Not Equal To

A10
Payee #1 (LEA)

Refill Too Soon Carry Over

A12
Days Supply

Refill Too Soon LTC Carryover

A13
Day Supply

RTS Exceeds Monthly

A15
Maximum Quantity LTC

RTS Exceeds Monthly

A16
Maximum Quantity

Payment Denied Exceeds

A19
LOS Certification

More Specific Diagnosis

A22
Required

More Specific Procedure

A23
Code Required

Not A Preferred Drug Call 1-

A24
800-252-8942

1 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Preferred Drug Call 1-800-

A25
252-8942 For PA

Concurrent/Continued Cert
A29
Required

Bill Multi-Eligibility Segments

A30
on Separate Claims

Recipient Eligible For Moms

A31
And Babies
NDC Not Covered For Critical
A32
Care Provider
Coinsurance + Ded > HFS
A36
Allowed Amount

Missing/Invalid Taxonomy
A38
Code

APL/HCPCS Code Required

A39
on Claim
Invalid Void or Void/Rebill
A40
Transaction
Void/Rebill is Past Timely
A41
Filing

A44 Inconsistent Service Date

2 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Missing/Invalid Claim Paid

A46
Date

A48 SASS Involvement Required

A49 Discharge Planning Involvemen

Service Not Covered Without

A50
Modifier U1

Service Allowed For

A51
FQHC/ERC/RHC Only

Transportation Modifier Invalid

A52
for Service

Bill Multi-CMH Eligibility on

A53
Separate Claims

A54 CMH - No Certification on File

A56 CMH - One Day Stay

A57 Duplicate of Encounter Claim

Procedure/Modifier/POS
A59
Combination Invalid

Service Not Covered-Bill as

A60
DME Claim

3 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

NDC Requires PA/Generic

A61
Does Not

A62 NDC Not Covered

A64 Bill Hospice

Bill Fluoride Varnish

A66
Separately

COS Not Authorized In

A67
Contract
Service not Authorized in
A71
Contract
Date Of PMT Outside
A72
Contract Agreement

DHS Recipient Only - Review

A76
Claim

No Medicaid Application was

A77
Filed
Interagency PMT AMT
A79
Unacceptable

Past Timely Filing Match

A81
Claim

A82 Service is not Payable by HFS

A83 Suspended for DHS Review

4 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

A88 No Certification on File

Invalid Technical/Prof
A90
Component Billing

OTC Drug not Covered for All

A91
Kids Recip

A97 Void/Rebill Hold

Qty Dispensed Exceeds Qty

B04
Prescribed

Dispensing Status not P C or

B05
Blank

No Partial for Completion this

B06
Rx

Multiple Partial Fills not

B07
Allowed

Invalid Quantity to be
B10
Dispensed

5 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Invalid Days Supply to be

B11
Dispensed

Qty to be Dispensed < Qty

B12
Dispensed

Day Sup to be
B13
Dispensed<Day Sup Disp

B14 Invalid Prescriber ID Qualifier

B15 Missing Prescriber Last Name

Invalid Primcare Physician ID

B16
Qualifier

Primcare Physician Invalid for

B17
Qualifier

Invalid Compound Route of

B21
Administration

6 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Other Payer Date > Process

B22
Date

Ingredient Cost For

B23
Compound = 0

Compound NDC not on HFS

B24
File

Compound NDC Determined

B26
Obsolete

B27 Brand Name Limit Exceeded

Compound NDC Price not on

B28
HFS File

Manufacturer not Eligible for

B29
Quarter

Invalid Other Payer Coverage

B30
Type

Ingredient Qty For Compound

B31
=0

7 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Other Payer ID Qualifier not

B32
Equal 99

B33 Invalid TPL ID Code

B34 Other Payor Date Invalid

Other Payer Amt Pd Qualifier

B35
not Equal 08

B36 Missing/Invalid TPL Amount

Reason for Service Code

B58
Invalid

Professional Service Code

B59
Invalid

B60 Result of Service Code Invalid

Not Eligible For Part D Copay

B62
Billing

8 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Compound Prior Approval not

B63
on File

Compound PA not on File for

B64
Fill Date

Compound Item Group Care

B66
Restricted

Compound Item not Covered

B67
for Aid Category

Compound Quantity Exceeds

B68
HFS Maximum

Compound Quantity Less

B69
Than HFS Minimum

Compound Professional Fee

B71
Invalid

Compound Item Invalid for

B72
Recipient Sex

9 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Compound Item Invalid for

B73
Recipient Age

Compound DESI Drug not

B75
Allowed

Compound MFGR not on File

B76
for Rebate

Compound MFGR not on

B77
FILE for Rebate/DOS

Compound NDC Approval not

B78
on HFS File

Compound NDC was

B79
Terminated on *

Compound Item Part B -Bill

B80
Medicare

10 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Compound Ndc Ppu Is Equal

B81
Zeros

Compound Not Covered For

B82
Critical Careprov

Compound Item is not

B83
Preferred Drug

Compound Item Preferred

B84
Drug- PA Required

Other Payment Segment not

B90
Allowed

Invld Other Payer Amt Pay for

B91
Cover Code

Invld Other Payer Rej Cd for

B92
Cover Code

11 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Other Payment Segment

B93
Required

B94 Part D Service – Bill Medicare

NDC not Cvrd for Part D

B95
Copay Only Billing

Compound has a Duplicate

B96
NDC

Duration of Therapy
B97
Exceeded

Qty Billed Not Multiple Of Pkg

B98
Size

C01 NDC/Item Number not on File

Additional Information
C02
Required

C03 Illogical Quantity

12 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

C04 Pricing Review

Maximum Quantity Limit

C05
Exceeded

NDC/Item Number Invalid on

C06
Date of Service

Local Tax Available for

C07
Tuberculosis Treatment

Psych Care Limited for

C09
Recipient Age

Frequency Digit and Claim

C10
Type Indicator Disagree

Non-Covered Days do not

C11
Balance with Dates

C12 Item Number Miscoded

13 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

C14 Item/Service not Allowed

C15 Procedure not from ICD‑9-CM

Procedure not Covered by

C16
HFS

C17 Place of Service Illogical

Abortion Form Invalid/Not

C18
Attached

Sterilization Form Invalid/ Not

C19
Attached

14 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

C20 Diagnosis not from ICD‑9

Category of Service Requires

C21
Renal Revenue Code

Emergency Charges not Valid

C22
for Clinics

Revenue Code Invalid for

C23
Category of Service

Primary Diagnosis Info

C26
Required

C28 Missing HFS Payer

C30 Invalid Payer Sequence

C31 Procedure not on File for Date

Procedure Illogical for

C32
Category of Service

C33 Procedure Illogical for Role

15 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

TOS=Surgeon/Modifier=
C35
Surgical Assistant

Revenue Code Requires

C45
Noncovered Amount
Valid Accident/Injury Code
C47 Required for Emergency
Services

Invalid Accident/Injury Code

C48
Req

Review of
C50 Procedure/Diagnosis
Information

C60 Diagnosis Code not Allowed

Diagnosis/Procedure not DRG

C61
Groupable

C63 Service not Covered as Billed

Admit Through Discharge

C64
Claim Required

Illogical Patient Status for

C68
Billing Status

16 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Anesthesia Unit Exceeds

C71
Department Maximum

Minutes/Units Exceeds
C72
Department Maximum

No Principal Proc Code/ Data

C75
in Other Procedure Code

Invalid Modifier For Service

C82
Billed

Invalid Number of
C84
Tests/Procedure Code

Coinsurance and Deductible

C86 Illogical for Stay Less than 61
Days

Suspend for Prepay Review/

C87
Diagnosis

Prepay Review Rejection/

C88
Diagnosis

17 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Not Payable Based on

C89
Medicare Determination

C90 Invalid Professional Fee

Invalid Admit Date for Interim

C91
Claim

Missing/ Invalid HCPCS for

C92
ER REV Code

Department Will Reprocess

C93
Claim

Review Charges and Submit

C94
Corrected Claim

Procedure/ Service must be

C95
Billed on UB Invoice or 837I

No Payable Service on
C97
Claim/Rebill

Prepay Review Rejection/

C99
Procedure

18 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

D01 Duplicate Payment Voucher

Exceeds Daily Maximum

D02
Dose

Invoice does not Contain

D03
Provider Signature

Suspended for Department

D04
Review

Submitted Later than One

D05
Year After Service

Procedure Date Outside Per

D06
Diem Range

Claim Receipt Prior to Billing/

D08
Service

19 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Accommodation Days not

D09
Equal Covered Days

Admission Date Greater Than

D10
Service Date

Inpatient/ Outpatient Claims

D15
for Same Day

Quantity Billed Requires Prior

D17
Approval

Undefined Error — Contact

D25
Department

Inpatient or Group Care Claim

D33
on Same Day

Undefined Error — Contact

D35
Department

Prior Approved Total Quantity

D36
Exceeded

Place of Service Requires

D37
Facility Name

Submitted Later Than 2 Years

D45
After Service

20 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Review of Submittal
D50
Information

D74 Duplicate of Pending Claim

Multiple Dates of Service on

D77
ERC Claim

Optical Prescription Order

D78
Required

Item has NDC/Rebill

D80
Pharmacy Claims System

NDC Not Covered/ Mfgr not

D82
on File for Rebate

NDC Not Covered/ MFGR

D83
NOF for Rebate on DOS

NDC/Item Number not

D88
Approved on File

NDC/Item Number not Priced

D89
on File

Manufacturer not on File for

D90
Rebate Quarter

21 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Psychiatric Care not Approved

D91
as Billed

E01 Missing Recipient Name

E02 Missing Recipient Number

E03 Invalid Recipient Number

E04 Missing Date of Service

E05 Invalid Date of Service

E06 Missing Prescription Number

E07 Missing NDC

E08 Invalid NDC/ Item Number

E09 Missing Quantity

E10 Invalid Quantity

22 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

E11 Missing Provider Number

E12 Invalid Provider Number

E13 Missing Provider Name

Repeat Following Deleted

E14
Service

Missing/Invalid Group
E15
Indicator
Missing Prescribing
E19
Practitioner No

Invalid Prescribing Practitioner

E20
No

E21 Invalid Payee Code

23 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Invalid COS-
E22
Specialty/Subspecialty

E23 Invalid Type of Bill

E24 Missing/Invalid Patient Status

Missing/Invalid Admission
E27
Date

Missing/Invalid Admission
E28
Hour

E29 Invalid Through Date

Missing/Invalid Newborn Birth

E32
Date

Bill Type and Taxonomy

E33
Conflict

Missing/Invalid Procedure
E34
Date

24 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

E35 Invalid Diagnosis Prefix

Missing/Invalid Diagnosis
E36
Code

Missing/Invalid Type of
E37
Admission

Family Planning Service

E40
Invalid for Age

E45 Invalid HCPCS Code

E47 Missing/Invalid Revenue Code

E48 Invalid Units of Service

Missing/Invalid
E49
Accommodation Rate

E52 Invalid Non‑Covered Charges

E53 Missing/Invalid Total Charges

25 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Missing/Invalid Total Service

E54
Charge

Missing/Invalid Item or
E55
Procedure Code

Missing/Invalid Non‑Covered
E56
Days
Invalid PRO/QIO Approval
E57
Code

E60 Invalid Spenddown Amount

Occurrence Span from Date

E63
Invalid

Occurrence Span through

E64
Date Invalid

E65 Invalid Covered Days

Mothers Discharge Date

E68
Required/ Occ Code 53

E69 Missing/Invalid TPL Code

Missing/Invalid TPL Status

E70
Code

26 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

E71 Missing/Invalid TPL Amount

Valid Unit Required for

E72
Epogen

Missing/Invalid Total
E73
Deductions

Missing/ Invalid Total Net

E74
Amount

E75 Missing/Invalid Billing Date

Procedure Date not Equal

E78
Service Date

E80 Invalid Units for Observation

Occurrence Span From Date

E81
Greater Than Through Date

From Date Greater Than

E82
Through Date

No Ancillary Revenue Code

E83
Identified

E84 Incorrect Covered Days

Missing/Invalid Referring
E85
Practitioner Number

27 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

E86 Missing/Invalid From Date

Missing/Invalid Other
E88
Physician ID

No Covered Revenue Code

E89
Identified

Missing Attending Practitioner

E90
Name

Missing/Invalid Attending
E91
Physician Number

Missing Referring Practitioner

E92
Name

Missing/Invalid Renal Dialysis

E95
Place of Service

Renal Dialysis Ancillary

E97
Charge not Shown

Late Ancillary Claim Shows no

E98
Charges

F01 Payment Reduced

Quantity Reduced to
F02
Department Maximum

28 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Revenue Code 001 Total

F04
Recomputed

Recipient Name/Number has

F08
Been Corrected

Provider Name/Number Has

F09
Been Corrected

Recipient Number Has Been

F11
Corrected

Recipient Name Has Been

F12
Corrected

F13 Net Charge Recomputed

Provider Name Has Been

F15
Corrected

Provider Number Has Been

F16
Corrected

29 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Third Party Source Not

F17
Identified

TPL Amount Greater Than

F18
Department Maximum

F19 Payee (Pay To) Corrected

F20 Total Charges Recomputed

Accommodation Total
F21
Recomputed

F26 Total Deductions Recomputed

Service Date Format

F27
Corrected

Place Of Service Format

F28
Corrected

F29 Amount Format Corrected

30 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Number Of Sections Total In

F30
Error

Recipient Not On File For

F34
Medicare

F36 Invalid Secondary Diagnosis

F37 Possible Error In Charge

Payment Reduced For

F39
Co‑Payment

Spenddown Not Applied/ QMB

F44
Recipient

F47 Newborn Payment

F49 Invalid Payment Date

F52 Eyeglasses Fabricated

F53 Eyeglasses Not Fabricated

31 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Eyeglasses Not Fabricated

F54
Exceeds Limit

F55 Replacement Part Authorized

Replacement Part Not

F56
Authorized

F60 Invalid E/I Procedure Code

NDC Obsolete/Check Label

F66
For Accuracy

NDC Obsolete/ Check

F68
Obsolete Date

Payment Reduced To Max

F69
Qty Allowed

F70 Payment Based On DRG XXX

32 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Invl/Missing CLIA Cert For

F72
Date Of Service

Payment Date Greater Than 2

F75
Years Old

Suspended For Pre‑Pay

F76
Review/ Newborn

Suspended For DRG

F77
Reassignment/ Review

Suspended For Prepay

F78
Review

Rev Code Invalid For

F80
Medicare Recipient

Expired License Submit Proof

F84
Of Renewal

F85 Medical License Expired

33 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Service Must Be Billed

F89
Through CBO

Payment Reduced To HFS

F94
Allowable For Visit

X‑Ray Procedure Reduced To

F96
HFS Allowable

Lab Procedure Reduced To

F97
HFS Allowable

PMT Reduced To HFS

F99
Allowable For Service

Missing Invalid Claim

G06
Received Date

G11 IHC PCP Referral Required

PA Required For LTC

G26
Recipient

34 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

G27 Prescriber Not Authorized

Not Paybl Pt Mcare Elig Bill

G29
Other Payer

Adj Ended Due To Negative

G32
Liability

G33 Missing/Invalid Qualifier

G35 Hospital Acquired Condition

Missing/Invld Cond
G37
Cde/Admin Denial Code

Recipient In MCO – Integrated

G39
Care

Integrated Care Recipient Has

G40
Medicare

Miss/Inv Contractor/MCO Pay

G41
To Provider

35 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Missing/Invalid Administrative
G42
Denial Code

Drug Requires PA For This

G43
Client

Appropriate Birthing Ctr

G45
Proc/Rev Code Req

Exceeds HFS Max Scripts/30

G47
Days

Recipient Has No Waiver

G49
Eligibility
Chiropractor Serv
G50
Inappropriate For Diag

Submitted Later Than 180

G55
Day Filing Limit

LTC Limited To 14 Day Supply

G58
Per Fill

G60 Recipient In A Voluntary MCO

Serv Not Covered Without

G61
Mod GP, GO, GN

36 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Inappropriate Procedure
G62
Combination

Recip Not Elig For Smoking

G65
Cessation

Prior Authorization Req For

G67
Procedure By QIO

Bill FP Device fee-for-service

G70
on Separate Claim

G71 Encounter Data Hold

Serv Class Auth Does Not
G72
Match Serv Pkg
Client Not Assigned To
G75
Provider

IMD Waiver-Allow Only W

G76
Addtnl Men Hlth Serv

Provider Type Invalid For

G77
Submitter
Prov Authorization For DMH
G79
Legacy Only
G80 DMH FY Contract Not On File

37 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

DMH Provider Registration

G81
Not On File

Recipient DMH Blanket

G82
Authorization Not Found

Recipient Service Class

G83
Authorization Not Found

Recipient Service Quantity

G84
Exceeded

No Usable Funds Auth For

G85
Recip/Prov Combination

G86 Missing Qrtly Review

Missing DHS Allowed Amt

G87
(Spec Elig) Code

Exceeds Service Package

G88
Limits
Procedure/Modifier Combo
G89
Not Utilized
Prior Auth Not Allowed For
G90
Recipient Age

Proc/Mod Combo Not Incl In

G91
Prov Authorization

38 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

G92 ICG Rate Not On File

Modifier Invalid For DHS

G93
Social Service
Prov Type 036 Must Bill
G94
Electronic
Provider Not Authorized For
G95
Group Psych
Psych Service Not Allowed
G96
For LEA

Psychiatric Certification Not

G97
On File

Psychiatric Residency Not On

G98
File

G99 Diagnosis Not Psychiatric

H01 No DHS Service Segment

39 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

H02 Recipient In SASS Program

Recipient Not Eligible For

H03
Service
DHS Segment Missing For
H04
Non MRO Service

Service Not Covered-Recip

H05
IDOC/IDJJ

Zero Covered Days Not

H07
Billable
Cont Homecare Maximum
H09
Units Exceeded
Appropriate Epo NCPCS
H11
Required
Hospice DOS Overlaps
H12
Calendar Months
H16 Missing/Invalid NDC
Synagis Days Supply Must
H19
Equal 30
H20 Provider NPI Required
Duplicate CBSA Code Not
H21
Allowed

POA Present On Admission

H25
Indicator Req

Missing/Invalid
H26
Billing/Creation Date
40 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Missing Value Code For

H29
Covered Days
Missing/Invalid Amount For
H30
Value Code Covered Days

Missing/Invalid Value Code

H31
For Non-Covered Days

Missing/Invalid Value Code

H34 For Covered Days Series
Claim
Service Not Covered For
H36
DSCC
Service Not Matchable For
H37
LEA/DORS/OGP

H38 Not Covered By Mental Health

Billing Provider NPI Not

H39
Registered

NDC Not Found On Federal

H40
Rebate File

Client Not Covered For

H41
Telepsychiatry
H42 NPI Not Useable

H43 Missing/Invalid Attending NPI

41 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

H44 Missing/Invalid Operating NPI

Missing/Invalid Other
H45
Physician NPI

H46 Multiple NPI Registered

Procedure Code Combo Not

H47
Allowed

H48 Rendering NPI Invalid

H49 Payee NPI Not Valid

Payee (Pay To) Not Valid For

H50
Provider

H52 Rendering NPI Required

H54 Payee (Pay To) NPI Required

Missing/Invalid Rendering
H55
Provider NPI

Missing/Invalid Referring
H56
Provider NPI

Missing/Invalid Estimated
H75
Medicare Liability Amount

42 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Provider Charge Exceeds

H86
Dept Allowable

H87 DMH FY Contract Not On File

H98 Mapper Hold

One segment Overlaps

H99
W/Other Segmt RDB Hold

Payment Reduced To Max

I01
Allowable Miles

Payment Reduced By
I03
Copayment

AllKids PMT Reduced By

I04
Copayment

AllKids Payment Reduced

I05
Copay/Coinsurance

Veterans Payment Reduced

I06
Copay/Coinsurance

Veterans Payment Reduced

I07
Copay/Coinsurance

MSG/Invld Ordering/Referring
I09
Practitioner NPI
43 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

I10 Missing/Invalid NDC

I15 Billing Provider NPI Required

I30 Rendering NPI Missing/Invalid

Encntr CCP Rate Prev Pd For

I32
Date Of Service

Non-Emergency Use Of
I33 Emergency Room Co-
Payment Applied
I34 Rate Reduction

I35 Institutional Claim Hold

Cesarean Section Reduced To

I36
Vaginal Delivery

Provider Preventable Readmit

I37
Rate Reduction

I46 Modifier Invalid For Service

340b Sub Clar Must=20 &

J04
Basis Of Cost Det=08

340b Sub Clar=20 & Bas.Cost

J05
Determ.Not Prsnt

44 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

340b Sub.Clar.=20 & No

J06
Cibcd Code = 08

Sub.Clar.Code Not 20 & Cibcd

J07
Code = 08

Family Planning Clinic Payee

J17
Only
Missing NIPS Drug
J40
Dispensing Fee

Limit 2 Group Psych Visits In

K01
7 Days

External Cause Code is not

K02
from ICD-10

K03 Diagnosis is not from ICD-10

K04 Procedure is not from ICD-10

Claim crosses 10/01/15; must

K05
be split

K06 ICD Code/Dates Conflict

Admitting Diagnosis Not From

K10
ICD-10

External Cause Code Invalid

K11
as Principal Diagnosis

45 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

K12 Invalid DX for Date of Service

Service Intensity Add-on

K16
Billing Invalid

Routine Home Care Days

K17
Paid at High Rate

Recip In County Care - Prior

K39
Auth Req

Serv Not Covered by County

K40
Care

Recip In Ctycare.PA Req:Call

K41
*

Renal Services Invalid as

K42
Billed

L08 Missing/Invalid Exhaust Date

Missing MDS Assessment

L09
Date

46 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Missing/Invalid LTC Segment

L10
for Recipient

LTC Claim Must Be a Single

L11
Calendar Month

L12 Invalid Claim Submittal

Client Does Not Meet Age

L13
Restriction

Invalid Agency Code/Dates for

L14
Recipient ID

Occur Code or Rev Code

L15
Invalid for Claim

Exceptional Care Services

L16
Invalid as Billed

L18 Missing Value Code

L20 Invalid Medicare Payor Loop

47 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Accommodation Days not =

L22
Statement Period

Value Code Inconsistent with

L23
Statement Period

L24 Bill Medicare Advantage Plan

Missing Procedure
M06
Description
Missing Purchase/ Rental
M18
Code

Missing Origin/ Destination

M20
Place Code

Missing/ Invalid COS-

M22
Specialty/Subspecialty

M23 Missing Type Of Bill

M24 Missing Patient Status

M27 Missing Admission Date

M28 Missing Admission Hour

48 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

M29 Missing Thru Date

Newborn Occurrence Code

M31
Required

M32 Missing Newborn Birth Date

Bill Type and Taxonomy

M33
Conflict

M36 Missing Diagnosis Code

M37 Missing Type Of Admission

Missing/Invalid Procedure
M44
Code/Date

M47 Missing Accommodation Code

M48 Missing Units Of Service

M49 Missing Accommodation Rate

49 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

M50 Missing Charge

Missing Revenue Line For

M51
Total Charge 0001
M53 Missing Total Charges

Missing Procedure Code

M55
/Drug Code

M56 Missing Non‑Covered Days

Missing Occurrence Span
M63
From Date
Missing Occurrence Span
M64
Through Date

M65 Missing Covered Days

Mother’s Discharge Date

M68
Required/OCC Cd 53

M69 Missing Third Party Source

50 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

M70 Missing TPL Status Code

M71 Missing TPL Amount

M72 Missing/Invalid TPL Date

M73 Blank Tot Deduct

M75 Bill Date Missing

Missing/Invalid Vehicle
M77
License Number
M78 Missing Pricing Segment

Missing Non‑Covered
M81
Occurrence Span Code

M85 Miss Ref Prac Nbr

M87 Missing From Date

M88 Missing Other Physician Id

Missing Attending Physician

M91
Number

51 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Missing/Multiple Payees (Pay

M93
To)

N01 Invalid primary diagnosis code

N02 Invalid 2nd diagnosis code

N03 Invalid 3d diagnosis code

N04 Invalid 4th diagnosis code

N05 1st diagnosis not ICD-CM.

N06 2nd diagnosis not ICD-CM.

52 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

N07 3d diagnosis not ICD-CM.

N08 4th diagnosis not ICD-CM

1st diagnosis invalid for date

N09
of service

2nd diagnosis invalid for date

N10
of service

3rd diagnosis invalid for date

N11
of service

4th diagnosis invalid for date

N12
of service

1st diagnosis invalid for

N13
recipient age

2nd diagnosis invalid for

N14
recipient age

3rd diagnosis invalid for

N15
recipient age

4th diagnosis invalid for

N16
recipient age

53 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

1st diagnosis invalid for

N17
recipient sex

2nd diagnosis invalid for

N18
recipient sex

3rd diagnosis invalid for

N19
recipient sex

4th diagnosis invalid for

N20
recipient sex

O39 Recipient in MCO

Makena Limited To 35 Day

O94
Supply

Provider Not Eligible For

P01
Category Of Service

Provider Not Enrolled For

P02
Category Of Service

54 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Provider Not Enrolled For

P03
COS/Date Of Service

Invoice Invalid For Provider

P04
Type

P05 Provider Number Not On File

Provider Name Does Not

P06
Match Provider Number

Service Not Allowed Per

P07
Department Review

Fee‑For‑Service Invalid For

P09
UB Bill

P13 Tax Levy Exception

Reported Payee (Pay To) Not

P15
Found

Service Under Review By

P18
Exception Review
55 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Services Not Allowed By

P19
Provider Services

P20 RX Practitioner Not Identified

Prov Not Enrolled In Vaccine

P46
Program

Inactive Provider/Returned
P48
Mail Contact Department

Review Of Provider
P50
Information
Monies Diverted To IRS For
P52
Tax Levy

Care Not Appropriate For

P59
Children’s Hospital

Care Not Appropriate For

P60
Adult Hospital

Payee (Pay To) Not Certified

P66
With State Comptroller

56 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

DRG Reassignment Review

P67
Rejection

P68 Prepay Rev Rej/One Day Stay

Prescribing Physician Is
P70
Terminated By HFS

P74 Occurrence Code Required

Payee (Pay To) Valid For CBO

P81
Payment Only
Provider Type Not Valid For
P83
Claim
Procedure Illogical For
P93
Provider

Prov Type/ Doc CD/COS

P97
Comb Not Allowed

P98 Default Pay-To Provider Used

Provider Uncollected
P99
Debt/Contact Department

Original NDC Not Allowed

Q01
Prof Service
57 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Q02 Missing Prescriber First Name

Originally Prescribed NDC Not

Q03
On Db

Missing Primary Care

Q04
Provider Last Name

Q39 Recipient In MCO-LTSS

No Record Of Recipient
R01
Number

Recipient Name Does Not

R02
Match Recipient Number

Recipient Not Eligible On Date

R03
Of Service

R04 Recipient Is Enrolled In MCO

58 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Service Restricted Group

R05
Care Recipient

Recipient Not Eligible On Date

R06 Of Service/ Spenddown Not
Met

Prior Approval Denied-

R08
Established Patient

R09 Prior Approval Required

Service Not Covered For

R10
Recipient Category

Hysterectomy Form Invalid Or

R11
Missing

Prior Approval Prov Number

R14
Does Not Match

R15 Patient Deceased

59 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Services Invalid For Recipient

R16
Sex

Services Invalid For Recipient

R17
Age

Suspended For New Born

R18
Eligibility Review

Correct Spenddown Credit

R23
Not Shown

Newborn Not Eligible For

R24
Assistance

Care Not Authorized By

R29
Primary Pharmacy

60 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Care Not Authorized By

R30
Primary Physician

Recipient Category Changed

R33
Mid‑Stay

Services To Mental Health

R34
Recipient Limited

R35 Part A Service- Bill Medicare

R36 Part B Service- Bill Medicare

Recipient Has Prepaid Full

R39
Service Plan

R40 Group Care Item Only

61 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

R41 Prior Approval Not On File

Prior Number Not On File For

R42
Date Of Service

HCPCS Procedure Code

R43
Required

Obsolete Code ‑ New HCPCS

R45
Code Required

Obsolete Code ‑ See Current

R46
CPT

Type Of Care Requires

R48
Authorization

R50 Review Of Recipient

Review Of Chronic Renal

R51
Dialysis Information

Spenddown Information
R52
Discrepancy

62 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

R53 Review Of Prior Approval

QMB Recipient Only Not

R66
Eligible For Medicaid

Services Not Covered For

R74
MPE

NDC Not Covered On Date Of

R77
Service

DESI Drug Not Allowed For

R78
Payment

Services Not Covered For

R79
GA- Adult Only- Case

R84 Recipient Age Consistency

R86 NDC Is Terminated

Participation Agreement Not

R88
On File

Invoice Invalid For Hospice

R89
Patient

63 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Diagnosis Inappropriate For

R90
Hysterectomy

Recipient Not Enrolled For

R96
Hospice

Hospice Claim/ No LTC

R97
Revenue Code

Services Invalid For Interim

R98
Application

Standards Of Care Agreement

S03
Not On File

Special Handling Req -

S54
Contact Department

Missing Sbhs Cost

S99
Data/Pricing Rate

TPL Amount Indicates Status

T03
Is Incorrect

64 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

TPL Status Indicates TPL

T05
Amount Required

Third Party Date Implies

T07
Illogical Status

Required TPL Code For

T09
Medicare Is Missing

T10 TPL Adjudication Date Illogical

Insufficient TPL Data-Contact

T12
Department

T16 Update Company Table

Recipient Has Third Party

T21
Coverage

65 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

T22 TPL Source Not Equal RDB

Third Party Source Not

T32
Identified

T35 TPL Status Invalid

Submittal Time Limit/TPL

T36
Status 07 Not Met

TPL Edit Bypass Pregnancy

T37
Related

TPL Edit Bypass Preventative

T38
Services

T39 TPL Greater Than Charges

Medicare Beneficiary Has

T40
Additional TPL

66 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

T41 Missing Medicare Payer

T43 Provider Must Bill TPL

T44 Additional 910 MB Invalid

Verify TPL. If Correct Request

T45
PA

TPL Invalid On Illinois

T46
Medicaid Line

T47 No Medicare Allowed Amount

Missing Coinsurance And/Or

T48
Deductible Amts

T50 Review Of TPL Information

Telehealth Originating/Distant
T87
Invalid

Telehealth Distant Provider

T89
Invalid

67 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Telehealth Originating
T96
Provider Invalid

Telehealth Distant Place of

T97
Service Invalid

T98 Telepsychiatry Provider Invalid

Telehealth Originating Place

T99
of Service Invalid

Duplicate Drug
U01
Therapy/Previously Disp

U06 Approval Of Stay Not Entered

Interim Claim Must Be At

U14
Least 30 Days

Missing/Invalid New/Refill
U16
Indicator

68 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Exceeds Authorized Refill

U17
Number

Missing/Invalid Number Of
U18
Days Supply

Exceeds Maximum Days

U19
Supply

U20 Missing/ Invalid DAW Code

Missing/Invalid Date Rx
U21
Written

Date Rx Written After Date Of

U22
Service
Missing/Invalid Compound
U23
Code

U25 Refill-Too-Soon

Missing/Invalid Covered Days

U26
For Series Bill
Series Days Exceed Date
U27
Span
Series Units Less Than Days
U28
Billed

69 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Multiple HAR Groups Not

U29
Valid For Series Bill

Series Bill Exceeds Allowable

U30
Date Span
Series Bill Revenue Code
U31
Required
Procedure Not Valid For
U32
Series Bill

U33 Refill-Too-Soon-LTC

U34 Diagnosis Not Valid For Date

Non‑Covered Occurrence
U35 Span Dates Outside
Statement Covers Period
Non‑Covered Occurrence
U36
Spans Overlap
Claim Type X Invalid For
U37
Hospice

Hospice/LTC REV Code

U38
Invalid For Recipient

Duplicate Rx Number For

U43
Different Recipient

70 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

U44 Duplicate ECP Submission

Duplicate Rx Number For

U45
Different NDC

Missing Bed Reserve 41 For

U49
Hospice Claim

Renal Revenue Cd
U51
Combination Not Allowed

Procedure Code Not Allowed

U53
For Nurse Practitioner

Service Only Allowed For

U54
Child

ASTC Crossover Cannot Be

U55
Billed On UB

ASTC Service Invalid For

U56
Document Type

Provider Not Allowed To Bill

U58
For Service

Diagnosis Code Not Allowed

U59
For Service

71 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Service Units Greater Than

U60
Covered Days

U62 Anesthesia Modifier Required

Type Of Bill Invalid For

U64
Provider Type

NDC Not Valid For Date Of

U65
Service

Missing HCPCS Code For

U66
Revenue Code

Epogen Charge Required For

U67
Value Code 68

Incorrect Covered Days For

U68
Renal Services

Admitting Diagnosis Not From

U70
ICD‑9

U71 E‑Code Not From ICD‑9

Invalid Admitting Diagnosis

U72
Code

72 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

E‑Code Invalid As Principal

U73
Diagnosis

U74 Invalid E‑Code

Missing Admitting Diagnosis

U75
Code

General Care Not Approved

U76
For COS 21

Condition Code Required For

U80
Abortion

Procedure Invalid For

U81
Condition Code

Multiple Abortion Condition

U82
Codes Invalid

Recip Not Enrolled By Prov

U83
On DOS

Outpatient Series Claim

U84 Crosses 07/01/04 Must Be
Split

73 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Non-Covered Occurrence
U85 Span Dates = Statement
Dates

DPH Renal Claim Crosses

U87
Calendar Months

Missing / Invalid Value Code

U88
Info For Hospice

Recipient Is Not
U91
DCFS/Service Not Covered

Provider Not Authorized For

U92
DCFS Screening

Nurse Pract/Midwife Not

U94
Enrolled For COS

Invalid Type Of Service/Role

V21
Code

Invalid Sterilization/ Abortion

V22
Code

Missing/Invalid Place Of
V23
Service

Missing/Invalid Provider
V24
Charge

Missing/Invalid Balance
V25
Due/Net Charge
74 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Missing/Invalid Number Of
V26
Services

Anesthesia Requires
V27
Modifying Units

Missing Referring Practitioner

V41
Number

Missing/Invalid Purchase/
V60
Rental Code

Missing/Invalid Orig Or Dest

V61
Place Code

W37 Invalid Medicare Payment

Invalid Medicare Cash

W39
Deductible

W41 Invalid Medicare Coinsurance

Invalid Medicare Payment

W42
Date

Medicare Assignment Code

W44
Not Yes

75 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

W60 MCE Plan Code Defaulted

Recipient Not Enrolled In

W61
Designated Plan

W62 Provider Affiliation Mismatch

W71 Missing Origin Facility Name

Missing Destination Facility

W72
Name

W73 Invalid Unit/Miles

Missing/Invalid Origin Or
W74
Destination Time

Cash Deductible Exceeds

W77
Maximum
Coinsurance Exceeds
W78
Maximum

Missing Deductible/
W79
Coinsurance

Days Billed Exceed Days In

W82
Service Range

W83 Invalid Number Of Total Units

Suspended For Information

W84
Update

76 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Number Of Renal Dialysis

W87
Services Exceed Maximum
Coinsurance Exceeds
W91
Medicare Payment
Medicare Part B Deductible
W92
Exceeds Maximum

Medicare Allowable Exceeds

W93
Total Charges

Service Under Review By

X01
Medical Quality Assurance

One Initial Office Visit/ Exam

X03
Allowed

X04 Consultation Disallowed

77 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

X05 Hospital Visit Disallowed

Surgical Package Previously

X06
Paid

Maternity Care Previously

X07
Paid

78 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Surgical Procedure Conflicts

X08
With Previously Paid Surgery

Lab Procedure Previously

X09
Paid

X‑Ray Procedure Previously

X10
Paid

79 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Procedure Conflicts With

X11
Program Limits

One Psychiatric Visit Per Day

X12
Allowed

Oxygen Charge Previously

X13
Paid

Anesthesia Service Conflicts

X14 With Previously Paid
Anesthesia

80 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

X15 Visit Previously Paid

Podiatry Procedure Conflicts

X16
W/Program Limits

Healthy Kids Visit Previously

X17
Paid

X18 Healthy Kids Visits Conflict

X19 Immunization Previously Paid

Healthy Kids Immunization

X21
One Time Only

81 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Measles/ Mumps/ Rubella

X22
Immunization Previously

Sickle Cell Test One Time

X23
Only

Renal Charge Daily/Full

X24
Month Previously

Complete Procedure
X25
Previously Paid

Equivalent Service Previously

X26
Paid

Component Services
X27
Previously Paid

Therapy Service Previously

X29
Paid

Procedure Conflicts With

X30
Program Limits

82 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Anesthesia Units Exceeds

X32
Department Maximum

Illogical Quantity For Tests-

X33
Rebill With Lab/X-Ray Report

Surgical Assist Time Exceeds

X35
Department Maximum

Encntr/Visit Prev Paid Same

X37
Recip/DOS

X40 Pricing Problem

X41 Prepay Review/DRG Code

X45 Missing/Invalid Date Of Birth

Date Of Birth Not Equal To

X46
Dept Files

Obsolete ICD-CM Third

X48
Diagnosis

83 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

Obsolete ICD-CM Fourth

X49
Diagnosis

X50 Review Of Pricing

X51 Review Of Initial Office Visit

X52 Review Of Consultation

X53 Review Of Hospital Visit

Review Of Visit/Surg/
X54
Procedure
X55 Review Of Maternity Care

X56 Review Of Surgical Procedure

X57 Review Of Lab Procedure

X58 Review Of X-Ray Procedure

Obsolete ICD-CM Secondary

X59
Diagnosis

Obsolete ICD-CM Primary

X60
Diagnosis

X62 Duplicate Service In Process

X68 Match Claim Hold

84 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Error
Message
Code

One Round Trip Per PA Per

X70
Day

Missing/Invalid Prior Approval

X73
Number

Missing/Invalid HCPCS For

X75
Obs Rev Code

X78 Bilateral Procedure

85 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

nt date or adjudication date is missing or invalid. Please correct and resubmit with the correct TPL payment date and amount or TPL adjudication date.

Pay To) Code received on the claim must always be "1" for LEA Providers.

detected a pattern of refills where insufficient quantities of the previous prescriptions were consumed prior to the dispensing of the refill. Based on the participant’s fi
r drug being billed, the patient should have a sufficient supply of the drug. The patient should modify their prescription filling pattern in order to avoid continued rejec
y request a Refill-Too-Soon (RTS) override if valid justification exists. If the RTS override request is approved, resubmit the claim.

esidents of Long Term Care (LTC) facilities. The system detected a pattern of refills where insufficient quantities of the previous prescriptions were consumed prior to
of the refill. Based on the participant’s fill history of the particular drug being billed, the patient should have a sufficient supply of the drug. The patient should modify t
filling pattern in order to avoid continued rejections, or the pharmacy should modify their refill pattern. The provider may request a Refill-Too-Soon (RTS) override if v
exists. If the RTS override request is approved, resubmit the claim.

esidents of Long Term Care (LTC) facilities. Based upon the Department’s records for paid services for this participant, the current prescription’s quantity added to th
y paid services in the same therapeutic class, exceeds the recommended monthly maximum quantity for products in this class. The provider may request a Refill-To
de if valid justification exists. If the RTS override request is approved, resubmit the claim.

the Department’s records for paid services for this participant, the current prescription’s quantity added to the quantities for previously paid services in the same the
ds the recommended monthly maximum quantity for products in this class. The provider may request a Refill-Too-Soon (RTS) override if valid justification exists. If t
uest is approved, resubmit the claim.
days on the claim are greater than the total length of stay as determined by the Department's Peer Review Organization/Quality Improvement Organization (PRO/Q
certification/continued stay information received from the PRO/QIO and compare it to the covered/non-covered date information on the claim.

nal claim was submitted with an obsolete diagnosis code(s). For dates of service prior to 10/01/2015, refer to the ICD-9 coding manual. For dates of service on/after
CD-10 coding manual. Please correct and resubmit claim to the Department for processing.

nal claim was submitted with an obsolete procedure code(s). For dates of service prior to 10/01/2015, refer to the ICD-9 coding manual. For dates of service on/after
CD-10 coding manual. Please correct and resubmit claim to the Department for processing.

being billed is not a preferred drug. The Preferred Drug List (PDL) can be found on the Department’s Web site. Refer to "Web Site Resources" tab for link to PDL. P
act the prescriber to determine whether the patient can be switched to a preferred drug. If patient cannot be switched to a preferred drug, provider should submit a p
uest for the non-preferred drug. If the prior approval request is approved, resubmit the claim.

86 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

being billed is a preferred drug, but is in a therapeutic class that requires prior approval. Provider should submit a prior approval request. If the prior approval reque
esubmit the claim.

oncurrent/continued stay certifications of admission is not posted to the Department’s database with a matching RIN, provider ID, admitting diagnosis code, and adm
"Web Site Resources" tab for a link to the Department's Peer Review Organization/Quality Improvement Organization (PRO/QIO).

g Only. A claim was received for a participant who had two different eligibility types within the service date range. Please check the patient's eligibility through the ME
AVRS electronic verification systems and resubmit with dates of service having different eligibility types on separate claims. Links to the Department's eligibility syst
"Web Site Resources" tab.

submitted with a procedure code for an abortion and the participant has eligibility coverage under the Moms and Babies Program.

is not covered when billed by a Critical Care Provider.

of coinsurance and deductible remaining after adjudication by Medicare exceeds the Department's maximum allowable for the billed NDC.

submitted without a taxonomy code or an invalid taxonomy code. Review and resubmit claim with the appropriate taxonomy code. Refer to the taxonomy codes in C
4 and 5. A link to the Department's provider handbooks can be found on the "Web Site Resources" tab. If the claim was submitted with the correct taxonomy code,
nsultant at 1-877-782-5565 for assistance. For LTC, contact a LTC billing consultant at 1-844-528-8444 or 217-782-0545.

oes not contain at least one APL HCPCS code; or revenue code 450, 451, 456, or 762; or does not meet the criteria of being a DCFS screening claim. Refer to the "
tab for a link to the APL.

tion submitted on the void/rebill cannot be matched to an original claim. Review and resubmit void/rebill with the appropriate information.

was submitted more than twelve (12) months after the voucher date on the previously paid claim. The Department will not reprocess claims received more than twel
the original voucher date.

utpatient claims with dates of service on and after 07/01/04. The Revenue Code service line date is prior to the From Date or after the Through Date. Hospice claim
n and after 01/01/2007. For any Revenue Code 652, if the service line date is blank or the service date is prior to the From Date or after the Through Date or claim h
de lines 652 with the same service date. Claims with Revenue Codes 651, 655, 656, 657or 658 if the service line date is prior to the From Date or after the Through

87 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

er Claims: The date the claim was paid to the provider by the MCO must be provided in the K3 segment. The date must be logical, in the proper format and after th
date must be provided at the line level for professional claims and at the claim level for institutional claims. An example of a valid K3 segment is: K3*D820150930D8
ple the date the claim was received by the MCO was 9-30-2015 and the date the claim was paid by the MCO was 10-1-2015.

l Only. SASS involvement is required for all covered days submitted. Review dates of service billed on the claim. Refer to Web Site Resources tab for a link to the S

l Only. The claim was denied as Department files indicate there was no SASS involvement in discharge planning. Refer to Web Site Resources tab for a link to the

submitted for procedure code 36415 and no modifier. This procedure code is only covered when billed for blood lead draw and accompanied by the state defined “U

submitted with procedure code T1015. This procedure code is only covered for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) or Encoun
Cs).

submitted with a modifier designated for emergency transportation only. However, the provider taxonomy or COS submitted on the claim is not emergency transport
ical record to determine the correct billing information.

been received for a participant who is enrolled in the Community Mental Health Services (CMH) program for one date of service and eligible for regular Medicaid on
ce. The CMH dates of service must be submitted on a separate claim than the regular Medicaid dates of service.

l Only. The claim was denied as there was no PRO/QIO certification that matches the provider ID, RIN, admitting diagnosis, and admit date; and length of stay is gr
fer to the "Web Site Resources" tab for a link to the Department's Peer Review Organization/Quality Improvement Organization (PRO/QIO).

l Only. Claim was denied as Department files indicate no CARES or SASS involvement. Refer to Web Site Resources tab for a link to the SASS web page.

ant is enrolled in a Medicaid Managed Care Plan.

received with a Procedure/Modifier/Place of Service combination not recognized by the Department.

dressings and related supply items must be billed as a medical equipment/supply item using either the HIPAA 837P electronic billing format, or on paper using the
s Form HFS 2210 (Medical Equipment/Supplies) invoice; or by submitting the same data through the Departments' Medical Data Interchange (MEDI) system. Note t
gs are not covered for residents of LTC facilities. They are the responsibility of the facility.
88 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

available in generic formulation. Prior Approval is required for the brand name formulation to justify higher cost.

is not covered by the Pharmacy Program. Example of non-covered items are drugs indicated only for the treatment of erectile dysfunction.

received for a participant that is enrolled in a hospice on the Date of Service. The hospice is responsible for the cost of most drugs as a part of the hospice per diem
ubmitted to the hospice.

submitted with procedure code D1203 in conjunction with other procedure codes and/or more than one occurrence of D1203. Procedure Code D1203 must be bille
with no other procedure codes.

illed is eligible for the Other Government Payor (OGP) program, the provider can register for the COS and rebill.

ices restricted to Provider Type 036, Community Mental Health.

overnment Payor (OGP) can verify date. If date is correct, do not rebill. If incorrect date was billed, correct date and rebill.

t is not Medicaid eligible. Coverage is only through the Department of Human Services (DHS), which requires the claim to suspend for DHS to review to ensure that
has been completed for the participant before payment can be made.

not complete a MANG application for the participant.

ency payment amount is zero or exceeds the Department's allowable amount.

overnment Payor (OGP) can verify if the OGP code and date billed are correct as billed. If correct as billed, there is no action to take. If billed incorrectly, the OGP c
de and DOS billed and rebill the claim.

ling: A claim was submitted for a participant that has a case identification office number of 195, which identifies that the participant is an IDOC or IDJJ inmate. IDOC
for payment. Providers may contact the Department at 217-782-3541 for IDOC/IDJJ medical vendor information. LTC Billing: If this code is received on a remittanc
nts ineligible services at a State operated facility. Do not rebill.

ccurs for children who are only eligible for SASS services. The claim suspends for DHS to review to see if a Medicaid/All Kids application has been filed or if there is
n file. Refer to the "Web Site Resources" tab for a link to the SASS webpage.

89 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

l inpatient claims only. A claim was submitted with an admitting diagnosis code that requires the provider to contact the Department's Peer Review Organization/Q
t Organization (PRO/QIO) for an admission/concurrent continued stay review prior to inpatient admission. Refer to the "Web Site Resources" tab for a link to the De

received from a hospital, ASTC, lab or imaging center requesting reimbursement for the professional component only. The Department only reimburses a hospital, A
ter for the technical component or the global. A claim was received from a physician requesting the global or technical component with place of service inpatient hos
ospital, emergency room or ASTC. The Department will only reimburse a physician for the professional component when the procedure is performed in the following
tient hospital, outpatient hospital, emergency room or ASTC.

ing billed is an over-the-counter (OTC) item that is not covered by Medicaid. The participant is enrolled in the All Kids Premium Program on the date of service. The
mburse for most OTC items for individuals enrolled in the All Kids Premium Program, (Levels 1 and 2).

ill has been temporarily suspended for Department review. Do not resubmit. The final status will be reported on a future Remittance Advice.

received with a value in the quantity Dispensed Field (442-E7) that is greater than the value received in the Quantity Prescribed Field (460-ET). Please review disp
bmit a new claim with the correct values in these fields.

as billed with a value in the Dispensing Status Code field that was not “P”, “C,” or a blank (not a partial fill). Please review dispensing records. Submit a new claim w
es in these fields.

as billed with a value of “C” (completion) in the Dispensing Status Code (343-HD) field. The Department’s records do not contain a paid service with a value of “P” (P
ng Status Code field for this prescription number. Check dispensing records to ensure that a paid response was received from the Department for a partial fill. If a p
ists, contact a pharmacy billing consultant at 1-877-782-5565. If no paid partial fill exists, submit the partial dispensing claim and then, after the paid response is rec
ompletion dispensing claim.

as billed with the dispensing Status Code (343-HD) field marked as a partial fill. Department records indicate a previously paid partial fill for this prescription number
ce. Only one partial fill is allowed for a given prescription. If you are unable to identify the previously paid partial fill, please contact a pharmacy billing consultant at

as submitted with either non-numeric values or spaces in the Quantity Intended to be Dispensed (344-HF) field when this field is situationally required. Review billing
alue for this field. Resubmit claim with correct values. If there is a question about when this field should be completed, please contact a pharmacy billing consultant
r assistance.

90 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

as submitted with either non-numeric values or spaces in the Days Supply Intended to be Dispensed (345-HG) field when this field is situationally required. Review b
he correct value for this field. Resubmit claim with correct values. If there is a question about when this field should be completed, please contact a pharmacy billing
2-5565 for assistance.

the Quantity Intended to be Dispensed (344-HF) field that is less than the value in the Quantity Dispensed (442-E7) field. Review dispensing records to determine w
esubmit the claim with the correct values.

the Days Supply Intended to be Dispensed (345-HG) field that is less than the value in the Days Supply Dispensed (405-D5) field. Review dispensing records to de
is in error. Resubmit the claim with the correct values.

the Prescriber ID qualifier (466-EZ) field does not match a valid value in the NCPDP 5.1 Data Dictionary. For electronic submissions, please contact your software v
hether the value you are using is correct. For paper submissions, refer to the paper invoice billing instructions for the HFS 215 Drug Invoice for the completion of thi
eb Site Resources" tab for links to the NCPDP Companion Guide and instructions for the 215 Drug Invoice.

ber Last Name (427-DR) field is not completed. This is a required field. Please resubmit the claim with this field completed.

the Primary Care Physician ID Qualifier field does not match a valid value in the NCPDP 5.1 Data Dictionary. For electronic submissions, please contact your softwa
whether the value you are using is correct. For paper submissions, refer to the paper invoice billing instructions for the HFS 215 Drug Invoice for the completion of
e claim with valid values. Refer to "Web Site Resources" tab for links to the NCPDP Companion Guide and to instructions for the 215 Drug Invoice.

ant is locked into a Primary Care Physician (PCP) on the date of service. Based on the Primary Care Physician Qualifier and the Primary Care Physician Identifier re
was unable to identify the PCP in our files. Review billing records to ensure that these two fields are correct. If data was in error, resubmit the claim with corrected in
correct, please contact a pharmacy billing consultant at 1-877-782-5565 for assistance.

coded as a compound. The value in the Compound Route of Administration (452-EH) field does not match a valid value in the NCPDP 5.1 Data Dictionary. For elec
, please contact your software vendor to determine whether the value you are using is correct. For paper submissions, refer to the paper invoice billing instructions f
voice for the completion of this field. Resubmit the claim with a valid value. Refer to "Web Site Resources" tab for links to the NCPDP Companion Guide and instruc
voice.

91 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

as submitted with a date in the Other Payer Date (443-E8) field that is later than the date on which the Department received the claim. Please review dispensing rec
correct date that the other payer notified you of the disposition of the claim. Correct the Other Payer Date and resubmit the claim.

received for a compound, with the Ingredient Drug Cost field for one of the ingredients being equal to spaces or zeros. Resubmit the claim with a valid Ingredient Co
ent.

coded as a compound. The value in the Compound Product ID (489-TE) field for one of the ingredients does not match a valid value in the Department’s NDC datab
w dispensing records to verify that the correct NDC values were submitted. If an error was found please resubmit with the correct NDC. If the NDCs submitted were
act a pharmacy billing consultant at 1-877-782-5565 for assistance in identifying the NDC in error.

coded as a compound. The date of service for the compound is greater than three years after the obsolete date for one of the ingredients in the compound. The pha
n, resubmit the compound with either the Submission Clarification value of 08 (Process Compound for Approved ingredients) or substitute a therapeutically equivale

brand name drug was billed for a participant for whom the Department has already reimbursed for three brand name drugs in the previous 30 days. Pharmacist sho
see if patient can switch to an alternative generic drug. If prescriber and pharmacist determine that patient cannot be switched to an alternative generic drug, provid
or approval request for a Three Brand Name Drug Limit override. The provider must include sufficient clinical documentation to support the request.

coded as a compound. An error exists for one of the billed ingredients. Please contact a pharmacy billing consultant at 1-877-782-5565 for assistance when this err

coded as a compound. The manufacturer of one of the ingredients does not have a valid rebate agreement on file with the federal Centers for Medicare and Medica
e quarter in which the Date of Service falls. The Department can only reimburse for drugs manufactured by companies who have signed rebate agreements with CM
urers with signed rebate agreements is available on the Department’s Web site. Refer to "Web Site Resources" tab for link to Pharmaceutical Labelers with Signed R
. Please contact a pharmacy billing consultant at 1-877-782-5565 to determine which ingredient failed the edit. The pharmacy may, at their option, resubmit the com
ion clarification value = 08 (Process Compound for Approved Ingredients).

situation was reported, with a value of other than ‘01’, ‘02’, ‘03’, or ‘99’ in the Other Payer Coverage Type (338-5C) field, or if the Other Payer Coverage Type field ha
the Other Payments Count field (337-4C) must always equal “1.” Review billing records to determine the source of the error. Resubmit the claim with the correct val
e data appears correct, please contact a pharmacy billing consultant at 1-877-782-5565.

received for a compound, with the Ingredient Quantity field, for one of the ingredients equal to spaces or zeros. Resubmit the claim with a valid quantity for each ND

92 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received, reporting a TPL/COB situation, with a value of other than ‘99’ in the Other Payer ID Qualifier (339-6C) field. Review billing records to determine the source
mit the claim with the correct value as defined. If the data appears correct, please contact a pharmacy billing consultant at 1-877-782-5565.

the other Payer ID field (340-7C) does not match a value in the Department's data base. Please refer to the Third Party Liability (TPL) Resource Code Directory or
enefits Manager (PBM)—TPL Resource Code Directory. Links to these directories can be found on the "Web Site Resources" tab. The preference is to use coding f
esource Code Directory. If no match can be found on the PBM-TPL directory, please use a value from the TPL directory. Any questions related to correct coding sho
pharmacy billing consultant at 1-877-782-5565.

received with a date in the Other Payer Date Field that is not in a valid date format. Resubmit the claim after correcting the value in this field.

the Other Payer Amount Paid (431-DV) field is greater than zero and the value in the Other Payer Amount Paid qualifier field (342-HC) does not equal 08. Review b
etermine the source of the error. Resubmit the claim with the correct value as defined. If the data appears correct, please contact a pharmacy billing consultant at 1-
istance.

received with information indicating that payment was received from another insurance carrier but the value in the TPL Amount field was either blanks or zeros. Res
e corrected TPL information.

the Reason for Service (439-E4) field does not match a valid value in the NCPDP 5.1 Data Dictionary. For electronic submissions, please contact your software ven
hether the value you are using is correct. The Department does not require this element to process a claim so the pharmacy may, at their option, either correct the v
claim or delete the value from the field and resubmit the claim.

the Professional Service Code (440-E5) field does not match a valid value in the NCPDP 5.1 Data Dictionary. For electronic submissions, please contact your softw
whether the value you are using is correct. The Department does not require this element to process a claim so the pharmacy may, at their option, either correct the
claim or delete the value from the field and resubmit the claim.

the Result of Service (441-E6) field does not match a valid value in the NCPDP 5.1 Data Dictionary. For electronic submissions, please contact your software vendo
hether the value you are using is correct. The Department does not require this element to process a claim so the pharmacy may, at their option, either correct the v
claim or delete the value from the field and resubmit the claim.

ant is eligible for Medicare Part D on the date of service, but the participant is not eligible for payment of their Medicare Part D copays.

93 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

coded as a compound. One of the ingredients requires prior approval but no prior approval matching the product was found. If a drug requires prior approval when b
t requires prior approval when billed as an ingredient in a compound. The pharmacy may, at their option, resubmit the compound with the Submission Clarification v
mpound for Approved Ingredients) or request prior approval for the ingredient prior to resubmitting the compound.

coded as a compound. One of the ingredients requires prior approval but no prior approval matching the product was found for the date of service. If a drug requires
en billed individually, it requires prior approval when billed as an ingredient in a compound. The pharmacy may, at their option, resubmit the compound with the Subm
value = 08 (Process Compound for Approved Ingredients) or request prior approval for the ingredient prior to resubmitting the compound.

coded as a compound. One of the ingredients in the compound can only be reimbursed by the Department when the participant is not a resident of a Long Term Ca
records indicate that the participant was not residing in a LTC facility on the date of service. Review billing records to ensure that the correct date of service was sub
ervice was in error, resubmit the claim with the correct date. If the date of service was correct, the pharmacy may, at their option, resubmit the compound with the S
value = 08 (Process Compound for Approved Ingredients). If you have questions regarding this error, please contact a pharmacy billing consultant at 1-877-782-556

coded as a compound. One of the ingredients is not reimbursable because the participant is classified as a non-citizen receiving renal dialysis treatment. The pharm
resubmit the compound with the Submission Clarification value = 08 (Process Compound for Approved Ingredients). If you have questions regarding this error, pleas
lling consultant at 1-877-782-5565 for assistance.

coded as a compound. The billed quantity for one of the ingredients in the compound exceeds the Department's maximum allowable quantity for the NDC. The prov
or approval request, to request a maximum quantity override. If the maximum quantity override is approved, the claim may be resubmitted.

coded as a compound. The billed quantity for one of the ingredients is less than the Department's minimum allowable quantity for the NDC. The pharmacy may sub
uest, to request a minimum quantity override. If the minimum quantity override is approved, the claim may be resubmitted.

received for a prescription compound and the Professional Fee value on the Department's provider database is missing. Please contact Provider Enrollment Service
r assistance. Please indicate to staff that the error is related to the pharmacy's professional fee segment. Once the error has been corrected the claim can be resub

coded as a compound. One of the ingredients in the compound is not appropriate for the gender of the participant. The pharmacy should review claim for accuracy.
or, it should be corrected and the claim resubmitted. If the billing data is correct, the pharmacy may, at their option, resubmit the compound with either the Submissio
value = 08 (Process Compound for Approved Ingredients) or submit a prior approval request for a gender override. If the gender override is approved, the claim ma

94 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

coded as a compound. One of the ingredients is not appropriate for the age of the participant. The pharmacy should review the claim for accuracy. If the billing data
corrected and the claim resubmitted. If the billing data is correct, the pharmacy may, at their option, resubmit the compound with either the Submission Clarification v
mpound for Approved Ingredients), or submit a prior approval request for an age limit override. If the age limit override is approved, the claim may be resubmitted.

coded as a compound. One of the ingredients is identified as being in DESI status on the date of service. The Department cannot reimburse for DESI drugs. The ph
option, resubmit the compound with the Submission Clarification value = 08 (Process Compound for Approved Ingredients).

coded as a compound. The manufacturer of one of the ingredients does not have a valid rebate agreement on file with the federal Centers for Medicare and Medica
Department can only reimburse for drugs manufactured by companies who have signed rebate agreements with CMS. A listing of manufacturers with signed rebate
is available on the Department’s Web site. Refer to the "Web Site Resources" tab for link to Pharmaceutical Labelers with Signed Rebate Agreements. Please cont
lling consultant at 1-877-782-5565 to determine which ingredient failed the edit. The pharmacy may, at their option, resubmit the compound with the Submission clar
Process Compound for Approved Ingredients).

coded as a compound. The manufacturer of one of the ingredients does not have a valid rebate agreement on file with the federal Centers for Medicare and Medica
e quarter in which the Date of Service falls. The Department can only reimburse for drugs manufactured by companies who have signed rebate agreements with CM
urers with signed rebate agreements is available on the Department’s Web site. Refer to the "Web Site Resources" tab for link to Pharmaceutical Labelers with Sign
. Please contact a pharmacy billing consultant at 1-877-782-5565 to determine which ingredient failed the edit. The pharmacy may, at their option, resubmit the com
ion clarification value = 08 (Process Compound for Approved Ingredients).

coded as a compound. One of the ingredients requires prior approval, and there is no prior approval on file. If an NDC requires prior approval when billed individuall
r approval when billed as an ingredient in a compound. The pharmacy may, at their option, resubmit the compound with either the Submission Clarification value = 0
or Approved Ingredients) or request a prior approval for the ingredient. Refer to the "Web Site Resources" tab for a link to the Pharmacy Program homepage.

coded as a compound. One of the ingredients is identified on the Department's files as having a termination date prior to the date of service. The Department canno
er their date of termination. The pharmacy may, at their option, resubmit the compound with either the Submission Clarification value = 08 (Process Compound for A
or substitute a therapeutically equivalent drug that is not terminated. If questions arise, please contact a pharmacy billing consultant at 1-877-782-5565 for assistanc

coded as a compound. The participant has Medicare Part B coverage on the date of service. One of the ingredients is identified on the Department's files as being c
are Part B on the date of service. The pharmacy must first submit the claim to Medicare for adjudication. After Medicare adjudication, the claim should be submitted
with the TPL/COB elements completed, indicating the disposition of the claim by Medicare. If questions arise, please contact a pharmacy billing consultant at 1-877
ce.

95 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

coded as a compound. One of the ingredients contains a pricing error on the Department's files. Please contact a pharmacy billing consultant at 1-877-782-5565 pri
the claim.

received with an indicator in the Compound Code field indicating that the prescription is a compound. Critical Care pharmacies are not allowed to submit compound
tted in the Compound Code field.

coded as a compound. One of the ingredients is not a preferred drug. The Preferred Drug List (PDL) is posted to the Department’s Web site. Refer to the "Web Site
tab for link to the PDL. The pharmacy may, at their option, resubmit the compound with either the Submission Clarification value = 08 (Process Compound for Appro
or request prior approval for the ingredient prior to resubmitting the compound, or substitute a preferred drug for the ingredient that is non-preferred.

coded as a compound. One of the ingredients is a preferred drug that requires prior approval. The Preferred Drug List (PDL) is posted to the Department’s Web site
e Resources" tab for link to the PDL. The pharmacy may, at their option, resubmit the compound with either the Submission Clarification value = 08 (Process Compo
gredients) or request prior approval for the ingredient prior to resubmitting the compound.

ubmittal only: A value was submitted in the Other Coverage Code (308-C8) field indicating that no other insurance coverage exists for this claim. This conflicts with t
information in the TPL/COB fields. Please review billing records. If no other insurance exists, resubmit claim without information in the TPL/COB fields. If there was
of the claim by another insurance carrier, it must be reported in the TPL/COB fields. The value in the Other Coverage Code field should be changed to reflect the ap
fore rebilling. Detailed information regarding the coding requirements for TPL /COB reporting is available on the Department’s Web Site in Topic 304.5 (Third Party L
Companion Guide. Refer to "Web Site Resources" tab for link to the NCPDP Companion Guide. If you have questions regarding correct coding, please contact a ph
ltant at 1-877-782-5565 for assistance.

ontained a value of either "02" (Other Coverage Exists - Payment Collected) or "08" (Claim is billed for Copay) in the Other Coverage Code (308-C8) field, but the Ot
d (431-DV) value is blank or contains zeros; or the claim contains a value of "04" (Other Coverage Exists - Payment not collected) and the Other Payer Amount Paid
zeros. Detailed information regarding the coding requirements for TPL/COB reporting is available on the Department’s Web Site in Topic 304.5 (Third Party Liability
mpanion Guide. Refer to "Web Site Resources" tab for link to the NCPDP Companion Guide. If you have questions regarding correct coding, please contact a pharm
t 1-877-782-5565 for assistance.

as billed with a value of either "03" (Other Coverage exists - claim not covered) or "05" (Managed Care Plan Denial) or "06" (Other Coverage Denied - not a particip
"07" (Other coverage exists - not in effect on Date of Service) in the Other Coverage Code (308-C8) field, and either the Other Payer Amount Paid (431-DV) value is
r the value in the Other Payer Reject Code (472-6E) field is not a valid NCPDP rejection code. Please check the billing records and change the above referenced fi
ailed information regarding the coding requirements for TPL/COB reporting is available on the Department’s Web Site in Topic 304.5 (Third Party Liability) of the NC
Guide. Refer to "Web Site Resources" tab for link to the NCPDP Companion Guide. If you have questions regarding correct coding, please contact a pharmacy billin
t 1-877-782-5565 for assistance.

96 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received with an Other Coverage code other than "00" (Not specified) or "01" (No Other Coverage) and the Other Payer Segment(AM05) is not in the transaction. V
overage code is correct and resubmit with an Other Payer Segment (AM05).

ant is eligible for Medicare. The claim must be submitted to the participant’s Medicare Part D Prescription Drug Plan (PDP). This drug is not eligible for coverage by t
for a Medicare-eligible individual. The participant must adhere to the PDP’s formulary.

Part D co-payment only service was billed for a drug that is not covered by the Department.

received for compound in which the same NDC appears twice. Please review compounding records and resubmit the claim with the correct ingredients.

exceeded the recommended duration of therapy for the drug being billed. If the prescriber believes that it is appropriate to extend the therapy for the patient, the pha
efill-Too-Soon override using the Refill-Too-Soon Prior Approval Request Worksheet. The Refill-Too-Soon worksheet can be found on the medical forms page on the
s Website. Refer to the "Web Site Resources" tab for a link to the listing of medical forms.

bmitted is described on the Department's NDC database as being dispensed as a decimal quantity. The Quantity Dispensed value is not equal to the package size.
h the correct package size.

submitted for a service, item or NDC which is not in the Department's reference database. Refer to provider records to verify the identification number or code for th
. If an incorrect number was submitted, rebill with the correct item number.

nformation was provided to process the claim for payment. If the claim was for a covered service, submit a new claim with a brief service description shown in the pr
ield. Also, attach the appropriate report (Operative, Radiology, Laboratory, Pathology, etc.). If no formal report is available, attach a typed narrative description of the
edure. If the claim was for a covered drug item, rebill showing the drug name/form/strength/quantity in the procedure/description field, or if additional space is require
may be attached to the claim.

billing: A pharmacy service was submitted for a quantity less than the minimum allowed for the National Drug Code billed. If the quantity was entered incorrectly, reb
e correct information entered in the appropriate fields. If the quantity was billed correctly, contact the Pharmacy Prior Approval Unit at 1-800-252-8942. All other bil
ubmitted for a service which does not require any entry in the Days/Units field of the claim form. Rebill and leave this field blank. If the procedure/service was perform
n the same date of service, use the corresponding “unlisted” code for the additional service(s). A description of the service(s) must be shown on the claim or an attac

97 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

Status: If Status is “SS” (paper remit) or “P2” (MEDI), the claim has been suspended for Department review, and the final status of the service will be reported on a
Advice. If Status is “RJ” (paper remit) or “F2” (MEDI), the service has been rejected. Refer to the Practitioner Fee Schedule for the procedure code submitted; a des
ired in the Note field, and/or an attachment may be necessary. Resubmit corrected claim if payment is still being sought. Fee schedules are available on the Depar
efer to "Web Site Resources" tab for a link to the Medicaid Reimbursement page.

billed exceeds the Department maximum. Payment was reduced to the Department's maximum allowable for the service billed. Do not rebill.

submitted with an NDC/item number which was not shown as a valid code on Department files on the date of service. If either the NDC/item number or the date of s
correctly, rebill the service by submitting a new claim including the correct NDC/item number and date of service.

submitted with a diagnosis code identified for Tuberculosis treatment. The participant resides in a jurisdiction which levies a special tax for treatment of Tuberculosis
of Public Health office should be contacted for specific billing instructions. If funds are exhausted or if the county states they will only pay for certain services, contac
billing consultant at 1-877-782-5565 for assistance.

received from a psychiatric hospital for inpatient psychiatric services for a patient between the ages of 21 and 65. Inpatient psychiatric services provided by psychia
e covered only for participants age 21 and younger (up to age 22 for those receiving services immediately prior to attaining age 21) and for participants age 65 and o
ent records for correct birth date. If the original claim contained incorrect information, a new claim may be submitted.

ling: An institutional claim was received with a Type of Bill 012X (Hospital Inpatient – Medicare Part B only) with a Medicare Part A payment reported on the claim. R
rected claim. LTC Billing: A claim was received with a Medicare Payor Loop, but the Bill Class Digit within the Bill Type indicates the claim is not a Medicare claim.
edicare Payor Loop or correct the Bill Class with the Bill Type and resubmit the claim.

submitted and the number on non-covered days did not match the number of days reported in the non-covered occurrence span dates.

git drug item code was not proper for the item described. If the description is correct for the prescribed item, the provider should rebill using the correct item number.
was incorrect for the item, the provider should rebill using the correct description.

98 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

problems has occurred: 1) A claim was submitted for a drug not covered by the Department. Drugs not listed in the Drug Manual may be requested through Prior A
g information is needed to facilitate the review of the request: Patient name and address; Recipient ID number; drug name (strength, dosage, quantity or package si
medical necessity; name, address and Provider Number of the prescribing practitioner; and, if available, the name and address of the dispensing pharmacist. Requ
d to: Illinois Department of Healthcare and Family Services, Attention: Drug Unit ‑ Prior Approval, Post Office Box 19117, Springfield, IL 62794 ‑9117. Toll free: 1-800
800-642-7588. Upon notification that prior approval has been granted, a new claim may be submitted by completing the entire service section; or 2) A claim was su
upply or supplies not covered by the Department. Do not rebill; or 3) A claim was submitted for a service not allowed based upon the service description or due to an
d for the same date. Do not rebill.

nt was received with an invalid ICD-9-CM (or upon implementation, ICD-10) procedure code.

submitted for a procedure not covered by the Department’s Medical Programs. Review the medical record. If an incorrect procedure code was reported, rebill using
rror was made on the original claim, do not rebill. No payment can be made.

g: A claim was received for a procedure not normally performed in the reported setting. Determine whether the correct procedure code and correct place of service w
ncorrect, a new claim may be submitted with the correct information entered. If no error is detected but the provider feels the service was appropriate to the setting,
ith a letter explaining the appropriateness of the setting. Submit both in the Special Handling Envelope (HFS 2248). Institutional Billing: A claim was submitted for
ot normally rendered in the reported hospital setting. Refer to medical records to determine if the correct procedure code was used. Refer to the "Web Site Resource
edical Forms Request - Paper/Envelopes page.

submitted for abortion services. Either the required Form HFS 2390 (Abortion Payment Application) was not submitted or the form submitted was considered to be i
form was invalid, it will be returned with a copy of the claim and a letter specifying the rejection reason. If the form can be corrected or if the claim lacked the certifica
w claim with the form attached. Submit both in the Special Handling Envelope (HFS 2248). Refer to the "Web Site Resources" tab for a link to the Medical Forms Re
opes page.

submitted for sterilization services. Either the required Form HFS 2189 (Consent Form) was not submitted or the form that was submitted was considered to be inva
form was invalid, it will be returned with a copy of the claim and a letter specifying the rejection reason. If the form can be corrected or if the claim lacked the certifica
w claim with the form attached. Submit both in a Special Handling Envelope (HFS 2248). Refer to the "Web Site Resources" tab for a links to the Department's Med
Forms Request - Paper/Envelopes page.

99 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted with a diagnosis code which is not ICD‑9. Refer to medical records to determine the correct diagnosis and then refer to the ICD‑9 coding structure. If an i
ported, a new claim may be submitted with the correct code.

nal claim was received on which the taxonomy code billed indicated Renal Dialysis, but there was not a covered renal dialysis revenue code on the claim.

nt claim was received with a Revenue Code that was inappropriate for the Taxonomy Code billed. If an error was made, submit a corrected claim.

nue codes to verify that they are valid for the Category of Service (UB-92 only) or Taxonomy Code (UB-04, 837I or Institutional DDE) billed. If an error was made, su
aim.

submitted with no primary/principal diagnosis. For dates of service prior to 10/01/2015, refer to the ICD-9 coding manual. For dates of service on/after 10/01/2015, r
ng manual. Please correct and resubmit claim to the Department for processing.

mitted to the Department for payment consideration must have the payer (HFS) identified as Illinois Medicaid or 98916. HFS must be the payer of last resort.

caid must be reported as the last payer after any other third parties billed. Acceptable values are Illinois Medicaid or 98916.

received for a procedure code which is either an invalid code, not a valid code based on the service date, or a valid code which does not appear on Department files
uld refer to the medical record to determine whether the correct procedure code and date of service were reported. If an incorrect procedure or service date was rep
ust be submitted with correct information. If the correct procedure code and date of service were billed, resubmit the claim with a letter identifying the source of the c

submitted with a procedure code which is not appropriate for the taxonomy code allowed for the provider. If an incorrect procedure was submitted, rebill on a new cl
mation.

submitted with a type of service code (Field 23 E on HFS 2360 or Box 4 on the HFS 1443) which is inappropriate for the reported procedure. Submit a new claim w
pe of service code appropriate to the procedure code.

100 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted for a surgical assist with incorrect values in field 23E (Type of Service) and in the modifier area in field 24C. To bill for a surgical assist, the value in field 2
modifier area in field 24C must be left blank. Submit a new claim with the correct information.

contains a non-covered revenue code, the noncovered amount cannot be a zero.

submitted with an emergency service procedure code, but the accident/injury code was either invalid or missing in the appropriate field/FL. A new claim may be sub
es an appropriate entry.

submitted with a procedure code for an emergency room visit and place of service of “E” (Emergency Room). However, the appropriate accident/ injury code was no
(Other). Review medical record to determine the correct billing information. Submit a new claim with the correct information.

. The claim has been temporarily suspended for Department review. The final status of the claim will be reported on a future Remittance Advice.

arge was submitted with Diagnosis Code 99999 (Diagnosis Not Listed). Submit a new claim with the specific diagnosis code.

submitted with an illogical procedure and diagnosis combination, invalid 4th or 5th digit in the codes, or other ungroupable or invalid situations. Review the medical
assignment and submit a corrected claim.

ode can occur for two reasons: 1) An institutional claim for rehabilitation services has been received with a taxonomy code other than inpatient rehabilitation. A hospit
npatient rehabilitation to be reimbursed for rehabilitation services. 2) A claim was received that grouped into DRG 436, which is not a valid DRG for hospitals.

npatient (Inpatient Hospital services) claims from a DRG Hospital must be billed for the entire period covering admit through discharge. Submit a correct claim.

e of Bill Patient Discharge Status for conflicting information. (Example: Type of Bill indicates patient still hospital inpatient, or residing in a nursing facility, while Patien
ates patient was discharged.) Submit a corrected claim.

101 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ment has a maximum limit for anesthesia services of 0480 minutes (8 hours). If the value in the Days/Units field exceeds this limit, the service will reject. Review to e
mber of minutes was entered correctly (4 digit format). If the entry was incorrect, rebill on a new claim with the correct time. If the entry exceeds 0480 minutes, rebill o
correct entry and attach a copy of the Anesthesia Record. Mail to the Department in the appropriate Special Handling Envelope (HFS 2248). Refer to the "Web Site
tab for a link to Medical Forms Request - Paper/Envelopes page.

ment has a maximum time limit for Assistant Surgeon Services of 0480 minutes (8 hours). If the value in the Days/Units field exceeds this limit, the service will reject.
billing to ensure that the total number of minutes was entered correctly (4 digit format). If the value entered in the Days/Unit field was incorrect, rebill on a new claim
y in the Days/Unit field. If the entry in the Days/Unit field exceeds 0480 minutes, rebill on a new claim with the correct time and attach a copy of the Operative Report
in the appropriate Special Handling Envelope (HFS 2248). Refer to the "Web Site Resources" tab for a link to Medical Forms Request - Paper/Envelopes page.

submitted with procedure code information in Other Procedure Codes and Dates but no principal procedure was reported in the Principal Procedure Code and Date
vice prior to 10-01-2015, refer to ICD-9 coding manual. For dates of service on or after 10-01-2015, refer to ICD-10 coding manual. Submit a corrected claim.

nvalid please correct claim and resubmit. Modifiers can be found on the fee schedules for the type of provider or service. Fee schedules are available on the Depart
o "Web Site Resources" tab for a link to the Medicaid Reimbursement page.

hown in the Days/Units Field (HFS 2360, Field 24F) does not fall within the number of tests defined by the procedure code. The provider should review the claim to d
service was miscoded. Rebill on a new Form HFS 2360 completing the entire service section with the correct data. If no error can be detected on the claim, complet
ubmit it with a brief explanation of the value entered in the days or units field.

Crossover claim for less than 61 days has been received with an incorrect amount of coinsurance and deductible due. Review and submit a corrected claim.

. The claim has been temporarily suspended for Department review. The final status of the claim will be reported on a future Remittance Advice.

as been reviewed by the Peer Review Organization/Quality Improvement Organization (PRO/QIO) with one of the following results: 1) Chart was not available or cas
esubmit claim; 2) Partial denial of days ‑ submit a paper claim form to your Department billing consultant with a copy of the Advisory Notice from the Department's P
es - submit a paper claim form to your Department billing consultant with a copy of the Advisory Notice from the Department's PRO/QIO; 4) Full denial ‑ do not rebill.
e Resources" tab for a link to the Department's PRO/QIO.

102 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ubmitted is non-payable by the Department based on the denial reason reported on Medicare's Explanation of Medicare Benefits. The provider may request reconsid
e Carrier. If the claim was rejected in error, contact a billing consultant at 1-877-782-5565 for assistance.

dicates that there is a problem with the pharmacy's records on the Department's provider database. The provider should contact Provider Enrollment Services at 1-8
istance. Please indicate to staff that the error is related to the pharmacy's professional fee segment. Once the error has been corrected the claim can be resubmitte

f Bill is either 0113 or 0114, or Type of Bill Frequency is either 3 or 4, the Admission Date must be the actual admission date and will never be the same as the From
he Statement Covers Period. Submit a corrected claim. Note: DRG claims cannot be split.

utpatient claims only. If the date of service is prior to 07/01/04, and the claim contains revenue code 450 or 456, there must be at least one valid HCPCS code next t
e (except 0001) on the claim. If the date of service is on or after 07/01/04, the emergency department revenue code must have a corresponding HCPCS code as ide
ory Procedures Listing (APL) on the Department's Web site. Refer to "Web Site Resources" tab for link to the APL.

. The Department will reprocess the claim.

ges and submit corrected claim.

was rejected because the hospital billed on a HFS 2360 claim form with a CPT procedure code for an Ambulatory Procedure Listing (APL) service. Rebill on a claim
al DDE. Refer to the "Web Site Resources" tab for a link to the APL.

received from a clinic with an encounter and corresponding detail service procedure codes. None of the detail service procedure codes listed are payable, therefore
annot be paid. Review the medical record. If an error is found in the detail procedure codes, rebill the encounter using the correct codes. If no error is found, do not r
not payable.

as been reviewed by the Peer Review Organization/Quality Improvement Organization (PRO/QIO) with one of the following results: 1) Chart was not available or cas
ubmit a new claim. 2) Partial denial. Submit a paper claim form, reflecting the review results outlined in the PRO/QIO Advisory Notice, to your Department billing con
of the Advisory Notice. 3) Full denial ‑ Do not rebill. Refer to the "Web Site Resources" tab for a link to the Department's PRO/QIO.

103 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

g: A claim was received which is a duplicate of one previously paid. Check the provider’s payment records to verify that payment has been received. If no record of p
ct a NIPS billing consultant at 1-877-782-5565 for assistance. If the rejected procedure code was for a procedure or service, other than a lab test or x ‑ray, that was d
n the same date of service, rebill on a new claim using the appropriate corresponding "unlisted" procedure code. A brief description should be entered on the claim a
eport (or narrative description) attached. Submit in a Special Handling Envelope, Form HFS 2248. Institutional or DDE Billing: A claim was received which was a
ously paid to the billing facility or the claim overlaps a claim paid to another facility. If the paid voucher number given on the Remittance Advice cannot be identified b
act an UB billing consultant at 1-877-782-5565 for assistance. For LTC, contact a LTC billing consultant at 1-844-528-8444 or 217-782-0545. Refer to the "Web Site
tab for a link to Medical Forms Request - Paper/Envelopes page.

e quantity and days supply, the prescription exceeds the Department's calculated daily maximum dose. Review dispensing records to ensure that the correct quantit
e prescription were submitted. If incorrect values were submitted, resubmit the claim with corrected values. If the correct values were originally submitted, a prior ap
daily maximum dose override must be submitted. The prior approval must contain clinical justification. The claim may be resubmitted if the daily maximum dose ove

mission: The paper claim was submitted without a proper signature. Prepare and submit a properly signed claim. An original signature is required. Copies of signat
and will be rejected. Electronic Submission: The electronic record was received with either a blank or an “N” in the Provider Signature field. A new record should be
the Provider Signature field. Does not apply to UB claims.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

submitted more than twelve (12) months after the date on which the service was provided. Rebilled claims, as well as initial claims, received more than 12 months fr
ce will not be paid.

received on which the procedure date is not within the dates of service or the procedure date is the same as the discharge date but the procedure should be perform
tus. Review the medical record and Statement Covers Period; (Admission Date; Patient Status Code and procedure codes. Submit a correct claim. LTC Billing: Pr
ot fall within the statement covers period.

as submitted with a service date later than the billing date or the billing date is after the date of receipt by the Department. If the date of service or billing date was no
he original claim, a new claim may be submitted.

104 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

claim was received on which the value in Covered Days did not equal the sum of the service units listed for the Accommodation Revenue Code(s). Review the med
which value is correct. Submit a correct claim.

received on which the Admission Date billed on the claim is later than the From Date in the Statement Covers Period. Review the medical record to determine which
mit a correct claim.

records indicate an inpatient claim was submitted for the same service date(s) as an outpatient claim was paid or vice versa. Contact a UB billing consultant at 1-87
ce.

submitted for a quantity that exceeds the Department’s maximum allowed quantity. A quantity over the maximum allowed quantity requires prior approval. A prior ap
uld be submitted for this service. After receiving prior approval, rebill on a new claim.

as submitted with information which caused an unusual error condition. Contact a billing consultant at 1-877-782‑5565 for assistance.

im for same date of service. Group Care claim previously paid voided. No action needed.

as submitted with information which caused an unusual error condition. Contact a billing consultant at 1-877-782‑5565 for assistance.

approved on the prior approval request form has been exceeded. No additional payment can be made under the existing prior approval. If additional quantities of th
equired, a new prior approval request must be submitted.

service code for this service requires entry of the facility name. Verify that the place of service code was correctly entered on the claim. If no error is found, submit a
(Name and Address of Facility Where Service Rendered) completed.

Crossover claim was submitted more than twenty-four (24) months after the date on which the service was provided. Medicare Crossover claims received more than
nths after the Date of Service will not be paid. LTC Billing: Contact Department billing consultant at 1-844-528-8444 for assistance.

105 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

. The claim has been temporarily suspended for Department review. The final status of the claim will be reported on a future Remittance Advice.

was processed and found to match another claim in payable status which has not yet been reported on a Remittance Advice. Do not rebill.

submitted by an Encounter Rate Clinic showing more than one date of service. Each date of service requires its own claim. Submit new claims with only one date of

submitted for a Dispensing Fee, but no HFS 2803,Optical Prescription Order (OPO) was attached. Submit a new claim for the Dispensing Fee and attach the OPO
for the eyeglasses to be manufactured. Refer to the "Web Site Resources" tab for a link to the Department's Medical Forms.

submitted for an item that must be billed through the pharmacy system with an NDC. Rebill on NCPDP or a HFS 215 Drug Invoice. Refer to "Web Site Resources"
ns for the 215 Drug Invoice and the NCPDP Companion Guide.

ment can not pay for the requested NDC because the manufacturer is not enrolled in the Federal Rebate program. Refer to the "Web Site Resources" tab for a link to
ical Labelers with Signed Rebate Agreements.

ment cannot pay for the requested NDC because the manufacturer was not enrolled in the Federal Rebate program on the Date of Service. Refer to the "Web Site R
to the list of Pharmaceutical Labelers with Signed Rebate Agreements.

as submitted with an NDC for which an error exists on the Department's NDC database. Please contact a pharmacy billing consultant at 1-877-782-5565 for assistan

as submitted with an NDC for which an error exists on the Department's NDC database. Please contact a pharmacy billing consultant at 1-877-782-5565 when this e

cturer of the NDC does not have a valid rebate agreement on file with the federal Centers for Medicare and Medicaid Services (CMS) on the date of service. The De
mburse for drugs manufactured by companies who have signed rebate agreements with CMS. A listing of manufacturers with signed rebate agreements is available
s Web site. Refer to "Web Site Resources" tab for link to Pharmaceutical Labelers with Signed Rebate Agreements. If you have questions, please contact a pharma
t 1-877-782-5565 for assistance.

106 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

aining a principal psychiatric diagnosis code has been received. A general care hospital not enrolled for inpatient psychiatric services may only bill for three emergen
tient care. A hospital enrolled for inpatient psychiatric services must bill as inpatient psychiatric care. Review the Provider Taxonomy Code that was billed.

as submitted with the Recipient Name field blank. The exact patient name must be entered in first, middle initial, last name format as shown on the HFS Medical Car

as submitted with the Recipient Number field blank. Rebill on a new claim using the patient’s nine digit Recipient Identification Number as shown on the HFS Medica

as submitted with either non-numeric characters in the recipient number field or more or less than nine (9) digits. Rebill on a new claim using the correct nine ‑digit R
n Number as shown on the HFS Medical Card.

section was submitted with the date of service field blank. Rebill on a new claim by completing the entire service section including the date of service entered in the

section was submitted with a date of service format other than MMDDYY. Rebill on a new claim by completing the entire service section including the date of service
Y format.

mission: The service section was submitted with the Prescription Number field blank. Refer to prescription file and rebill by completing the entire service section inclu
number. Electronic Submission: The service was received with blanks in the Prescription Number field. Review prescription file and enter prescription number in a
esubmitting.

was not submitted on the claim. For physician administered or dispensed drugs, the corresponding NDC code is required.

as submitted with an item number or NDC which is not found in the Department’s file. The claim must be resubmitted with a valid item number or NDC.

g: A claim was submitted with a type of service code which requires an entry in the Days/Units field. Rebill with a four ‑digit entry. When billing for anesthesia or surgi
rvices, enter the duration of time in minutes: e.g., the entry for 1 hour and 10 minutes is 0070. OASA Billing: An OASA claim was submitted without the number of S
it correct claim.

g: A claim was submitted with non-numeric values in the Days/Units field. Rebill on a new claim with corrected four-digit entry in the Days/Units field. Pharmacy Bill
d with non-numeric characters in the quantity field. Submit a new claim with numeric value in the quantity field.

107 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

r number field on a NIPS claim has been left blank. All services have been rejected. The Remittance Advice has been sent to the provider number on Department file
to the submitted provider name. If the provider who received the Remittance Advice did provide the service(s) billed, rebill on a new claim including the correct Prov

received on which the provider number field (on a NIPS claim) contained non-numeric characters or all zeros. All services have been rejected. The Remittance Advi
rovider number on Department files, which corresponds to the submitted provider name. If the provider who received the Remittance Advice did provide the service(
ew claim including the correct Provider Number.

as submitted with the provider name field blank. All services have been rejected. The Remittance Advice has been sent to the provider name on Department files wh
to the submitted provider number. If the provider who received the Remittance Advice did provide the service(s) billed, rebill by completing a new claim including the
me.

cator was entered in the service section immediately following a service section which was deleted. The entire service section must be rebilled on a new claim. For
on proper use of repeat indicators, refer to the appendices providing technical guidelines on preparing paper claims in Chapter 200 handbook specific to the service
to the Department's provider handbooks can be found on the "Web Site Resources" tab.

up Indicator Code on claim is invalid. Please correct and resubmit.

ing practitioner number field has been left blank. Rebill on a new claim by completing the entire section including the prescribing practitioner number.

ing practitioner number field has been completed with a number which is not a Drug Enforcement Administration (DEA) number or a Social Security Number (SSN).
submitted incorrectly, rebill on a new claim form by completing the entire section including the correct prescribing practitioner number.

ode submitted is not identified in the Department's records. Refer to Provider Information Sheet for correct payee code. Submit new corrected claim. If the payee in
de Information Sheet is incorrect, contact Provider Enrollment Services at 1-877-782-5565 for assistance.

108 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

as submitted with an invalid COS-Specialty/Subspecialty. Review the current Provider Information Sheet for the appropriate COS-Specialty/Subspecialty for the item
If the information on the Provider Information Sheet is not correct, please update the IMPACT record. A new Provider Information Sheet will be sent once the IMPAC
ade in the Legacy MMIS claims processing system. Do not resubmit the claim until the new Provider Information Sheet is received. Refer to the "Web Site Resource
MPACT system.

received on which Type of Bill contained an invalid code. Submit corrected claim. LTC Billing: LTC claims must have specific bill types associated with certain cate
ch are derived by taxonomy codes). Correct either the Bill Type or Taxonomy Code on the claim and resubmit.

received on which the Patient Discharge Status contained an invalid code or was left blank. Review the patient records to determine the correct two ‑digit status indic
ect claim.

hospice or LTC claim was received on which the Admission Date was left blank or contained an improperly entered date. Submit correct claim ensuring that the Adm
red and in the correct format.

aims only: Submit a corrected claim ensuring that the Admission Hour is entered and in a 2‑digit format. Valid entries are from 00 through 23.

ect claim with the Statement Covers Through Date in the correct format.

ssion Type is 4 (newborn), Birth Date must be completed with the date of birth in a valid 8-digit format. Submit a correct claim.

n conflict with the Taxonomy Code for the provider type-Specialty/Subspecialty billed. Review and submit a corrected claim. Refer to the taxonomy codes in Chapte
4 and 5. A link to the Department's provider handbooks can be found on the "Web Site Resources" tab. If the claim was submitted with the correct taxonomy code,
nsultant at 1-877-782-5565 for assistance. For LTC, contact a LTC billing consultant at 1-844-528-8444 or 217-782-0545.

l Billing: An inpatient claim was received on which a procedure was indicated, but the corresponding date shown in conjunction with the Principal Procedure or Othe
Codes were not in the correct format. Submit a correct claim. Renal Billing: For Revenue codes 0634, 0635, 0636 and 0821, the service date is missing, invalid form
m date” or after the “service through date.” Please check the date and rebill the claim.

109 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted with an invalid Primary Diagnosis Code prefix. For dates for service prior to 10-01-2015 refer to the ICD-9 coding manual. For dates of service on or after
CD-10 coding manual. If the ICD-9 code or ICD-10 code contains a leading alpha character it must be included as part of the diagnosis code. Please correct and res
Department for processing.

submitted with either no code or an invalid code as the Primary/Principal Diagnosis Code or with an invalid code as one of the Other Diagnosis Codes. For dates for
1-2015 refer to the ICD-9 coding manual. For dates of service on or after 10-01-2015 refer to the ICD-10 coding manual. Please correct and resubmit a claim to the
for processing.

ype code must be coded 1, 2, 3, 4, or 5 for inpatient claims.

ure Code/Diagnosis Code received is not covered for the age of the participant. Review the claim and if an error was made, rebill. If no error was made on the origin
o payment can be made.

utpatient claims with dates of service on and after 07/01/04. The claim has rejected because the HCPCS code on the claim is formatted incorrectly; or the code is no
ent's database.

rrected claim with valid Revenue Code(s).

vice Units. If an error is found, submit a new, corrected claim. If the units of service are correct, contact a billing consultant.

PCS/Rates to determine if an accommodation rate was entered for each accommodation Revenue Code listed. Insert a decimal in the rate where indicated (e.g. 130
claim. Hospice Billing: Review HCPCS/Rates to determine if a rate was entered for each revenue code except 657 (Physician services). Insert a decimal in the rate w
ubmit a corrected claim.

py of the rejected claim to determine if the Non-Covered Charges are shown correctly. Submit a corrected claim.

submitted with the Total Charge field either blank or containing non-numeric characters. Submit a correct claim including the Total Charge.

110 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

l Charges and Total Non-Covered Charges. Verify that the figures are valid. The total Covered Charges must be greater than the total Non-Covered Charges. Subm
aim.

g: The claim was submitted with a missing or invalid procedure code or item in the service section. Institutional Billing: An inpatient claim was submitted with a mis
ipal Procedure code or Other Procedure Code(s). Review the medical record and rebill on a new claim including a valid procedure code. For dates of service prior to
o the ICD-9 coding manual. For dates of service on or after 10-01-2015 refer to the ICD-10 coding manual.

of Non-Covered Days must be either blank or numeric.

dition Codes for PRO/QIO approval indicator, to determine that a code was listed. Acceptable codes are C1 or C3. Submit a corrected claim.

received with Value Code 66 (Medicaid Spenddown Amount), but the Value Code Amount is missing or invalid; or Value Code 66 is not present. Submit a correct cla
plit Billing Transmittal attached.

received with the Occurrence Code 74, but the From Date is either missing or invalid. Submit a corrected claim.

received with the Occurrence Code 74, but the Through Date is either missing or invalid. Submit a corrected claim.

ubmitted in Covered Days was a non-numeric value. Submit a corrected claim.

sion date is prior to April 1, 2009, and the claim is paid based on per-diem logic, Occurrence Code 53 must be followed by the mother’s discharge date. Submit a cor

received with a missing or invalid Third Party Liability (TPL) code. Rebill on a new claim by completing the entire billing including a valid TPL code. Refer to TPL seg
nt's MEDI eligibility verification. Links to MEDI and to the TPL Resource Code Directory can be found on the "Web Site Resources" tab.

received with a missing or non-numeric TPL Status Code. Rebill by completing a new claim with a valid TPL Status Code. Please refer to the Third Party Liability (T
ode Directory or the Pharmacy Benefits Manager (PBM)—TPL Resource Code Directory. Links to these directories can be found on the "Web Site Resources" tab.

111 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

nt amount must be numeric.

nue Codes 634 or 635 are present, then Value Code "68" is required with the number of units listed. Submit a corrected claim.

received with either a blank or with non-numeric characters in the Total Deductions field. Rebill all services on a new claim with the correct value in the Total Deduct

received with either a blank or with non-numeric characters in the Net Amount field. Rebill all services on a new claim with the correct value in the Net Amount field.

received with either a blank or an invalid billing date. Rebill on a new claim including the billing date in the MMDDYY format.

ocedure and Other Procedure(s) code dates must be within the Statement Covers Period. Review the medical record to determine which date is in error, and submit

vice Units to verify that the observation service units correspond to Revenue Code 762.

received on which the From date is later than the Through date for the Occurrence Span listed. The From date must be earlier than the Through date. Review the m
termine which date is incorrect. Submit a corrected claim.

received on which the From date is later than the Through date in the Statement Covers Period. The From date must be earlier than the Through date. Review the m
termine which date is incorrect. Submit a corrected claim.

laim is for Skilled Care (hospital residing), Exceptional Care (hospital residing), DD/MI (hospital residing) or accommodation revenue code is 100, at least one ancilla
modation) revenue code must be present. Review the medical record and submit a corrected claim.

e of Bill, Covered Days, Non-Covered Days and Patient Discharge Status for consistency. Contact a billing consultant if assistance is needed.

received with either a blank or with non-numeric characters in Field 19 (Provider Number). Rebill on a new claim including both the name and the Provider Number
ctitioner.

112 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ement Covers Period-From Date. From date must be in valid format. Submit a corrected claim.

er Physicians ID. The claim was received with either a blank or invalid number in the NPI field. Submit a corrected claim with a valid NPI.

enue Code(s). A covered revenue code is required in addition to revenue code 001. Review the medical record and submit a corrected claim.

received with a value in Field 19 (Provider Name) but without the name of the attending practitioner or other source. Submit a new claim with the attending practition

nding Physicians ID. The claim was received with either a blank or invalid characters in the field. Submit a corrected claim with the Attending Physician’s NPI.

as received with a value in Field 19 (Provider Name) but without the name of the referring physician or other source. Submit a new claim with the referring practition

dition Codes. For outpatient ESRD the applicable Renal Dialysis Setting Code must be entered. Valid values are 71, 72, 74, 75 and 76. Submit a corrected claim.

enue Code(s). When the Taxonomy Code is ESRD Treatment (Outpatient Renal Dialysis, ESRD), the claim must contain Renal Dialysis Revenue Code(s) that appro
atient renal dialysis service provided. Submit a corrected claim.

ype of Bill frequency code is 5 the claim must contain Revenue Code(s) with charges greater than zero. Submit a corrected claim.

was reduced to the Department's maximum allowable for the service billed. Do not rebill. If a billing error was made, the provider may submit an adjustment.

billed was reduced to the Department’s maximum allowable for calculation of the reimbursement amount. If no billing error occurred, do not rebill. If a billing error w
may submit an adjustment.

113 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

l Charges and Non-Covered Charges. A claim was received with a total service charge which does not equal the sum of the individual charges. The Department has
the charges. The provider records should be changed to reflect the correct total service charge.

l Billing: The claim was received with an incorrect Recipient Identification Number or Recipient Name. The Department was able to correct the error. The provider’s
hanged to reflect the correct information.

l Billing: The claim was submitted with a provider name that does not match the name to which the provider number is assigned. Review the current Provider Inform
rrectness of the provider name. Take appropriate action to ensure that all future claims submitted to the Department include entry of the correct provider name.

g: The claim was received with an incorrect Recipient Identification Number. The Department was able to correct the error. The provider’s records should be changed
Recipient Identification Number.

g: The claim was received with an incorrect patient name. The Department was able to correct the error. The provider’s records should be changed to reflect the corr

as submitted with an incorrect net charge. Do not rebill. Informational message only.

submitted with a provider name that does not match the name to which the provider number is assigned. Review the current Provider Information Sheet for correctn
me. If the name on the current Provider Information Sheet is not correct, please update the IMPACT record. A new Provider Information Sheet will be sent once the IM
been made in the Legacy MMIS claims processing system. Do not resubmit the claim until the new Provider Information Sheet is received. Refer to the "Web Site R
to the IMPACT system.

g: The claim was submitted with a Provider Number other than that carried on Department files for the Provider Name shown on the claim. Review the current Provi
Sheet for correctness of the provider number. Take appropriate action to ensure that all future claims submitted to the Department include entry of the correct Provid

114 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received with a third party liability amount however; the source of the TPL payment was not identified. The provider should ensure that future claims include entry of
se refer to the Third Party Liability (TPL) Resource Code Directory or the Pharmacy Benefits Manager (PBM)—TPL Resource Code Directory. Links to these directo
"Web Site Resources" tab.

as received showing an amount paid by a third party resource which exceeds the Department's maximum reimbursement for the service. If a billing error was made,
y submit an adjustment. If no error occurred, no action is required and no payment will be made.

as submitted with a payee (Pay To) which did not correspond to information listed on the Provider Information Sheet. The Department will report claims receiving this
ctive payee (Pay To) entity listed on the Provider Information Sheet. Future claims submitted should include the correct payee (Pay To). If the information shown on
ormation Sheet is incorrect, or out dated, please update IMPACT. A new Provider Information Sheet will be sent once the IMPACT update has been made in the Lega
essing system. Refer to the "Web Site Resources" tab for a link to the IMPACT system.

claim was submitted with room and board total charges which do not equal the product of the room and board days times the room and board rate. The Department
e error. Provider records should be changed to reflect the correct room and board total charge.

claim was submitted with room and board total charges which do not equal the product of the room and board days times the room and board rate. The Department
e error. Provider records should be changed to reflect the correct room and board total charge.

he individual TPL amount fields as entered on the claim do not equal the amount shown in Total Deductions field. If an error occurred in the original submittal, subm
If no error occurred, no action is required.

submitted with an improper entry in the service date field. The provider should ensure that future claims include a service date in a 6-digit numeric MMDDYY format

submitted with an improper entry in the place of service field. The provider should ensure that future claims include a place of service entry in a one-letter code form
Billing Instructions for appropriate codes.

submitted with entries for money amounts in an incorrect format. Example: 10 00. Ensure that future claims include entries for money amounts in a Dollars/Cents fo

115 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received with an incorrect entry in the Total Service Sections field. The provider should ensure that future claims include a proper entry to reflect the total number of
mpleted on the claim. Do not include deleted sections. Optometrist: If this message appears but one or more services rejected, rebill the specific rejected services aft
ry corrections to billing information. Do not attach a new OPO.

s no Medicare coverage on file for date of service.

received with a secondary diagnosis code in an invalid format. Informational message only.

review for potential errors in provider billing charges

ment has deducted the authorized patient co‑payment from the total payment and paid the claim at the reduced amount. Copayment amounts can be verified when c
ough MEDI or REV/EDI systems. Refer to "Web Site Resources" tab for links to the Department's eligibility systems.

received with a TPL code of 906 (Spenddown) in the TPL Code field. The patient is a Qualified Medicare Beneficiary (QMB). Application of Spenddown is inappropri
adjudication of the service before billing the Department.

atient claim paid based on newborn payment methodology.

received with a payment date that was not numeric or the payment date was prior to the date of service.

submitted for a dispensing fee. This message is to notify the optical provider that eyeglasses will be fabricated by the Department of Corrections and mailed to the o
dispensing to the participant. If the dispensing fee claim was approved and paid, do not rebill; informational message only. If the dispensing fee claim was rejected, r
that caused the rejection and submit a new, corrected claim. Mail the claim to the attention of your Department billing consultant. Do not submit a new OPO.

as submitted for a dispensing fee but rejected because of errors or omissions in the patient eligibility fields of the claim. This message is to notify the optical provide
will not be fabricated by the Department of Corrections until a new, corrected claim has been submitted and adjudicated. Review the patient files and rebill on a new
tion to the patient name and Recipient Identification Number. Important: a new OPO must be attached to the rebilled claim.

116 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted for a dispensing fee. This message is to notify the optical provider that eyeglasses have not been fabricated by the Illinois Department of Corrections (DO
were previously fabricated by the DOC and dispensed within the 1-year limit for adults.

submitted for a service fee. This message is to notify the optical provider that a replacement part has been authorized and the Illinois Department of Corrections (DO
part to the optical provider. Do not rebill; informational message only.

submitted for a service fee but rejected because of errors or omissions in the patient eligibility fields of the claim. This message is to notify the optical provider that a
part has not been authorized and the Illinois Department of Corrections (DOC) will not be mailing the part to the optical provider until a new, correct claim has been
ated. Review the patient files and rebill on a new claim, with careful attention to the patient name and Recipient Identification Number.

eligible to bill Early Intervention services.

received for an NDC where the Obsolete Date is less than or equal to the Date of Service. Please check the Obsolete Date on this product to ensure that it is valid f

bmitted for this service has been obsolete for a period equal to or greater than three years from the Date of Service. Review the dispensing records and submit a ne
ect NDC.

ed more than the allowable quantity. The Department reduced the claim to the allowable quantity and paid the State Max amount allowed for quantity.

ment has been issued based on the Department's Diagnosis Related Group Prospective Payment System. This message notifies the provider of the particular DRG u
based.

117 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received and one of the following applies: 1) there is no CLIA certificate in the IMPACT system; 2) the CLIA certificate in the IMPACT system was expired for the dat
3) the services billed are not covered under the CLIA certificate in the IMPACT system for the date(s) of service. The service cannot be rebilled until the CLIA informa
MPACT. Do not resubmit the claim until a new Provider Information Sheet is received verifying that the update to IMPACT has been made in the Legacy MMIS claim
system. If the reason for the rejection is #3 above, please contact a billing consultant at 1-877-782-5565 for assistance. Refer to the "Web Site Resources" tab for a l
tem.

nity Mental Health provider's claim is over 2 years old. Provider may contact a billing consultant at 1-877-782-5565 to check if the claim qualifies for a time override.

as been temporarily suspended for Department review. Do not rebill. The final status of this claim will be reported on a future Remittance Advice.

as been temporarily suspended for Department review. Do not rebill. The final status of this claim will be reported on a future Remittance Advice.

as been temporarily suspended for Department review. Do not rebill. The final status of the claim will be reported on a future Remittance Advice.

ling: If the recipient has Medicare Part A, the hospice cannot bill Illinois Medicaid for hospice services except LTC.

received from a provider whose license number on record in the IMPACT system had expired for the date of service being billed. The service cannot be rebilled unti
tered into IMPACT. Do not resubmit the claim until a new Provider Information Sheet is received verifying that the update to IMPACT has been made in the Legacy M
essing system. Refer to the "Web Site Resources" tab for a link to the IMPACT system.

received for a provider whose license on record in the IMPACT system has expired. The service cannot be rebilled until a valid license is entered into IMPACT. Do n
til a new Provider Information Sheet is received verifying that the update to IMPACT has been made in the Legacy MMIS claims processing system. Refer to the "W
tab for a link to the IMPACT system.

118 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received for a participant in the Early Intervention (EI) Program. These services must be billed through the EI Central Billing Office (CBO). Contact the EI CBO at 1-

received exceeded the Department's maximum allowable rate for the visit billed. The payment rendered is the maximum allowed for the procedure code submitted.

received exceeded the Department's maximum allowable rate for combination x‑rays. Review the patient's medical record with the CPT definition of the procedure c
al claim. If a separate x‑ray procedure or an unusually large number of x-ray procedures were required because of the nature of the patient's injury or illness, the pro
nt reconsideration by submitting a properly completed adjustment. The adjustment must be accompanied by documentation supporting the medical need.

lab procedures were received which are components of a complete lab procedure. Payment has been reduced on this procedure so that payment for the individual
ceed the maximum allowable rate for the complete lab procedure.

received exceeded the Department's maximum allowable rate for the service billed. The payment returned is the maximum allowed for the procedure code submitted

er Claims, the date the claim was received by the MCO must be provided in the K3 segment. The date must be logical, in the proper format and after the date of se
e provided at the line level for professional claims and at the claim level for institutional claims. An example of a valid K3 segment is: K3*D820150930D820151001. I
date the claim was received by the MCO was 9-30-2015 and the date the claim was paid by the MCO was 10-1-2015.

submitted for a service, which requires a referral from the participant’s Illinois Health Connect (IHC) primary care provider (PCP), but no referral is posted on the De
al from the IHC PCP should be submitted for this service within 60 days of the date of service. After receiving a referral, rebill the service on a new claim. For help in
if there are questions about the referral system, please contact the Illinois Health Connect Provider Helpline at 1-877-912-1999.

bmitted is one that the Department requires a prior approval for a recipient in a long term care setting on the date of service.

119 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

al identified as the prescriber is not enrolled in IMPACT as being a provider type/Specialty-Subspecialty allowed to create prescriptions. Please verify the NPI of the
must be a physician, dentist, podiatrist, advanced practice nurse or physician assistant.

submitted for a participant who has Medicare coverage. The Department is not responsible for this claim. Please bill the claim to Medicare.

completed by Department. No further recoupments recommended at this time.

ms Only - A claim was received with an NPI entry in FL 78 or 79 and the Provider Type Qualifier Code was missing or invalid. If an NPI is reported in FL 78 or 79 a tw
pe Qualifier Code must be reported. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not rebill. No payment can be m

ns a hospital acquired condition code, payment reduced accordingly. Please refer to Chapter 200 Handbook for Hospital Services for additional information. Links to
s provider handbooks and to a list of Hospital Acquired Condition (HAC) codes can be found on the "Web Site Resources" tab.

er Claims, this error is generated if the claim has the condition code of 04 and no administrative denial code in the HCP04 segment or vice versa.

records reflect that the participant was enrolled in the Integrated Care Program (ICP) on the date of service. Refer to one of the Department's electronic verification
/EDI or AVS) to identify the health plan in which the participant is enrolled. Contact the appropriate plan for billing information. Links to the Department's eligibility sys
alth plan contacts can be found on the "Web Site Resources" tab.

as a Managed Care and Medicare Part A, please verify Medicare Part A and participant's eligibility.

er Claims, the pricing methodology and the amount that the MCO paid on the claim must be provided in the HCP segment. If a zero payment is reported by entering
e must also be a zero reported in HCP02. If a payment is reported by entering 01 through 13 in HCP01, HCP02 cannot be zero.

120 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

tted indicates that no payment made due to an administrative denial. Administrative denial code is missing from the HCP04 segment. Please correct and resubmit.

received for an NDC which is a controlled substance. The participant on the claim is identified on Department files as having a problem with controlled substances. P
dispense this drug is required.

CS/Rev Code combination for provider (Specialty/Subspecialty) type. Correct and resubmit claim to Department for processing.

received that exceeds the Department's limit of 4 scripts per a rolling 30 day period. This limitation applies to certain brand name and generic legend drugs. It will be
prior approval for the Department to consider payment for this claim.

as no eligibility for waiver on file for date of service.

services are only covered for children under age 18. The Department cannot be rebilled.

ds the 180 day timely filing requirement. The claim is not eligible for payment. Refer to Chapter 100 Handbook for additional information on 180 day timely filing requ
epartment's provider handbooks can be found on the "Web Site Resources" tab.

received for a participant who was in a long term care facility on the date of service. The NDC submitted is identified as being limited to a 14 days supply for LTC pa

service on or after 04-01-2013, the participant is shown on Department files to be enrolled in a MCO. It will be necessary to bill the MCO directly for payment of the
of the Department's electronic verification systems (MEDI, REV/EDI or AVRS) to identify the health plan in which the participant is enrolled. Links to the Departmen
d to a listing of contacts at Medicaid health plans can be found on the "Web Site Resources" tab.

sing modifier, please correct the claim by adding the appropriate modifier and rebill the Department.

121 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received with a delivery and transfer on the same date of service. These services are not reimbursable on the same day. Review the medical records and the coding
m for correctness. If an error is found, submit a correct claim. If all information was correct on the original claim, do not rebill.

limited to participants under 21 years of age and women who are pregnant or in their 60-day post partum period. No payment can be made for the service.

hospital claims: No prior approval from the Department's Peer Review Organization/Quality Improvement Organization (PRO/QIO) on file. Please verify prior autho
IO. If the procedure was elective and no prior authorization was obtained, the claim cannot be billed to the Department. Codes requiring prior approval can be found
F available on the PRO/QIO homepage. Refer to "Web Site Resources" tab for link to the PRO/QIO.

ning devices and services must be submitted on a separate claim. Cannot combine with other non-family planning services. Rebill family planning services on anothe

aim is on hold.

neligible for mental health services on date of service.

neligible for services under this provider on date of service.

ed, provider is not allowed to bill Illinois Department of Human Services, Office of Mental Health for this participant on the date of service.

s not associated with the Illinois Department of Human Services (DHS), Division of Mental Health in the HFS IMPACT system. Please contact DHS for assistance.

eligible to bill Medicaid services.

ntract information has not been received by the Department. Please contact Beacon Health Options (formerly ValueOptions).

122 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

n code is not on the Department's provider database. Please contact Beacon Health Options (formerly ValueOptions).

ation is found for the participant for the service billed.

r after 7/1/11 and the participant has an authorization for the service package but not an authorization for the service class.

authorization on file with the HFS has been exceeded. Contact Department of Human Services' mental health contractor to see if additional services can be authoriz

ment is not able to find an authorization on file for this provider and participant for the date of service.

allowed to render services to participant on the date of service. Please contact Beacon Health Options (formerly ValueOptions).

ant's OBRA code has not been received from Beacon Health Options (formerly ValueOptions). Therefore, the percentage to pay on the claim is unknown until the OB
s received.

authorization on file with the Department has been exceeded. Contact Beacon Health Options (formerly ValueOptions) to see if additional services can be authorize

Modifier combination invalid.

received for a date of service after 6/30/10. The participant was authorized for a benefit package/registration or service class authorization that is inappropriate for th
age.

received for a date of service after 6/30/10. The participant has the benefit package authorization/registration on file for the date of service, but the funding source fo
t found in the provider's contractual information.

123 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ot contracted with IL Medicaid to provide ICG services. Please contact a billing consultant at 1-877-782-5565 for assistance.

alid for mental health services. Please correct modifier and rebill the Department.

st bill claims electronically. Paper claims not allowed.

allowed to bill the Department for group therapy sessions.

nly allowed to bill for Individual and or Family/Group Psychotherapy Services. Provider is not authorized to perform Psychiatric Diagnostic Testing or Psychiatric Tre

record of the rendering provider having the required Child Adolescent Psychiatry Certification or a General Psychiatry Certification. Claim cannot be processed witho
for the provider being entered into the IMPACT system. Please update the record in IMPACT to reflect the provider's certification. Do not resubmit the claim until a
ormation Sheet is received verifying that the update to IMPACT has been made in the Legacy MMIS claims processing system. Refer to the "Web Site Resources" ta
CT system.

received for a provider who does not have proof of completion of a psychiatric residency or certification in Psychiatric and Mental Health Nursing on record with the
If the provider of service is a psychiatrist who has completed a psychiatric residency or a psychiatric APN who holds the appropriate certification, the IMPACT syste
eflect the certification. Refer to the "Web Site Resources" tab for a link to the IMPACT system. Do not resubmit the claim until a new Provider Information Sheet is re
t the update to IMPACT has been made in the Legacy MMIS claims processing system. If the provider does not hold the appropriate certification, they cannot bill fo

received for group psychotherapy and the diagnosis code was not valid. For dates of service prior to October 1, 2015, refer to ICD-9 for correct coding. For dates of
015 and after, refer to ICD-10 for correct coding. Verify coding and submit a correct claim.

received for a participant who does not have active eligibility for Illinois Department of Human Services' services. Contact the DHS RIN Unit at 1-800-385-0872.

124 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted to the Illinois Department of Human Services for a participant in the SASS Program. Resubmit the claim to HFS. Refer to the "Web Site Resources" tab
on the SASS Program.

s not eligible for the services billed.

ed are Illinois Department of Human Services' Social Services program covered services and participant does not have DHS Social Service eligibility. Contact the DH
5-0872.

been received for a participant who is an IDOC/IDJJ inmate, which is identified with a Local Office code of 195. Any service not performed in the inpatient, outpatien
oom setting must be billed to the IDOC or IDJJ medical vendor for adjudication. Providers may contact the Department at 217-782-3541 for IDOC/IDJJ medical ven

must have at least one covered day in order to bill the Department.

aims: The amount of homecare hours exceeds the maximum number of hours.

iate HCPCS code is missing for the Epogen.

ms cannot cross months. Services must be billed monthly.

was not submitted on the claim or is invalid. For physician administered or dispensed drugs, the corresponding NDC code is required.

nly available in 30 day dosage packs.

received by the Department on or after 5/23/08 and there was no NPI reported on the claim.

aims: Cannot bill duplicate CBSA codes.

Admission Indicator is required for all inpatient claims. Please refer to Chapter 200 Handbook for Providers of Hospital Services for additional information. A link to th
s provider handbooks can be found on the "Web Site Resources" tab.

date (UB-04) is missing or not reported in the correct format. Review and submit a corrected claim.

125 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ms only: Value Code 80 for covered days is missing.

field associated with Value Code 80 (covered days) is blank, zero, or non-numeric. UB-04 claims only: The number of covered days is to be reported right justified
s/cents delimiter.

ms only: If the claim contains Condition Code C3 and Value Code 81 (non-covered days) is missing or Value Code 81 is present but associated amount is blank or z
ns Occurrence Span Code 74 and Value Code 81 is missing or Value Code 81 is present but associated amount is blank or zero. The number of non-covered days i
ht justified to the left of the dollars/cents delimiter.

ms only: Series claims require the number of treatment days to be reported in covered days. Value Code 80 and amount for covered days is missing or invalid. The
s is to be reported right justified to the left of the dollars/cents delimiter.

pant eligibility and date of service with the Division of Specialized Care for Children (DSCC) at 1-800-779-0889.

neligible for services on date of service.

ode billed is not covered by Community Mental Health Services program. Verify code billed.

received by the Department on or after 5/23/08 and the claim contained a NPI that was not registered on the Department’s database.

received where the manufacturer of the NDC submitted is not on the Federal Rebate file. The Department will only reimburse for drugs where the manufacturer has
on file with federal CMS. Refer to "Web Site Resources" tab for link to Pharmaceutical Labelers with Signed Rebate Agreements.

neligible for services on date of service.

received by the Department on or after 5/23/08 and the claim contained a NPI that could not be cross walked to a HFS Provider Number.

received by the Department on or after 10/1/08 with an invalid NPI or the NPI was not reported for the Attending Physician, which is required on all claims except for
s services.

126 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received by the Department on or after 10/1/08 with an invalid NPI or the NPI was not reported for the Operating Physician, which is required on all inpatient claims,
nd outpatient physical rehabilitation services, if a surgical procedure is performed.

received with the “ZZ” Other Operating Physician Qualifier Code, but the corresponding NPI is invalid or missing. Review the claim and if an error was made, rebill.
n the original claim, do not rebill. No payment can be made.

s registered under multiple NPIs. Please contact Provider Enrollment Services at 1-877-782-5565 for assistance.

ns more than one encounter type. Informational encounter must be billed on a separate claim. Rebill each claim with only one encounter code and procedure code.

received by the Department on or after 3/23/09 and the claim contained a Rendering Provider NPI that was invalid.

received by the Department on or after 3/23/09 and the claim contained a Payee NPI that was invalid. Effective March 30, 2009, this error message is inactive.

To) entity not active in IMPACT system. Please register the Pay To entity in IMPACT. Do not resubmit the claim until a new Provider Information Sheet is received ve
o IMPACT has been made in the Legacy MMIS claims processing system. Refer to the "Web Site Resources" tab for a link to the IMPACT system.

aim with a valid rendering NPI.

ed without a Payee (Pay To) NPI. Please correct claim and resubmit to the Department for processing.

received with the “82” Rendering Provider Type Qualifier Code, but the corresponding NPI is invalid or missing. Review the claim and if an error was made, rebill. If
n the original claim, do not rebill. No payment can be made.

received with the “DN” Provider Type Qualifier Code, but the corresponding NPI is invalid or missing. Review the claim and if an error was made, rebill. If no error w
claim, do not rebill. No payment can be made.

ed Medicare liability amount must be in the MCR file. This amount should be reported in the HCP05 segment. Please correct and resubmit.

127 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ubmitted to the Department has been reviewed and rejected due to a discrepancy between the Medicare allowed amount and the Medicare payment amount. Resub
mpleted claim form to the Department for consideration of payment.

tract information from DMH. Do not rebill.

al Only: The claims are on a Department hold for the update to the mapper.

eligibility issue. Please verify eligibility through MEDI, REV/EDI or AVRS systems. Refer to "Web Site Resources" tab for links to the Department's eligibility systems

ayment reduced to the Department's maximum mileage allowed.

ayment was reduced by the participant's copayment. Copayment amounts can be verified when checking eligibility through MEDI or REV/EDI systems. Refer to "We
tab for links to the Department's eligibility systems.

ayment was reduced by the participant's copayment. Copayment amounts can be verified when checking eligibility through MEDI or REV/EDI systems. Refer to "We
tab for links to the Department's eligibility systems.

l Billing: The Department has deducted the authorized participant co‑pay/coinsurance from the total payment and paid the claim at the reduced amount. Copayme
ed when checking eligibility through MEDI or REV/EDI systems. Refer to "Web Site Resources" tab for links to the Department's eligibility systems.

g: The Department has deducted the authorized participant co‑pay/coinsurance from the total payment and paid the claim at the reduced amount. Copayment amou
n checking eligibility through MEDI or REV/EDI systems. Refer to "Web Site Resources" tab for links to the Department's eligibility systems.

l Billing: The Department has deducted the authorized participant co‑pay/coinsurance from the total payment and paid the claim at the reduced amount. Copaymen
ed when checking eligibility through MEDI or REV/EDI systems. Refer to "Web Site Resources" tab for links to eligibility systems.

Referring Provider's Individual NPI is missing. Correct claim and resubmit to the Department for processing.

128 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

e billed requires a valid NDC.

rovider's NPI is either missing or invalid. Correct the claim and rebill the Department.

received on or after 3/23/09 and the Rendering Provider NPI was missing or invalid. Do not rebill; informational message only.

received from a Critical Care Pharmacy for a participant for whom a previous claim was paid on the same date of service. Only one reimbursement is allowed for a
on a given date of service, to a Critical Care Pharmacy.

al Only: Co-payment deducted from total for non-emergency use of the ER.

al Only: Due to the SMART Act (P.A. 97-689), the reimbursement is reduced by 3.5%.

al Only: Institutional claims are on hold by the Department.

al Only: Claim was reviewed by the Department's PRO/QIO to determine the medical necessity of a C-section. It was determined not to be medically necessary; th
een paid at the vaginal delivery rate.

al Only: The reimbursement rate is being reduced due to provider preventable readmission. Please refer to Chapter 200 Handbook for Providers of Hospital Service
formation. A link to the Department's provider handbooks can be found on the "Web Site Resources" tab.

ed on claim is invalid for services rendered. Please resubmit claim with the correct Modifier.

s submitted with values in either the Submission Clarification Code or Basis of Cost Determination Code that indicate the drug is a 340B drug. 340B drugs require th
Clarification Code = 20 and the Basis of Cost Determination = 08. All other coding will cause the claim to fail.

received with a Submission Clarification value of "20", indicating a 340B drug. A 340B drug also requires the completion of the Basis of Cost Determination field. Re
oth the Submission Clarification = 20 and Basis of Cost Determination = 08 fields completed.

129 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

claim was received with a Submission Clarification value of "20", indicating a 340B drug. The Compound Basis of Cost Determination field, for the 340B drug, did n
Resubmit the claim with valid values in both the Submission Clarification and Compound Basis of Cost Determination fields.

claim was received with a Compound Basis of Cost Determination field value of "08" indicating a 340B drug. The Submission Clarification value was not = "20". Res
alid values in both the Submission Clarification and Compound Basis of Cost Determination fields.

ure code billed is restricted to family planning providers only.

ment's database is missing the Drug Dispensing Fee. Please contact a NIPS billing consultant at 1-877-782-5565.

group psychotherapy service was billed for a participant that exceeds the Department’s limit of two (2) sessions in a seven (7) day period. Review a copy of the rej
records to determine whether the correct information was shown on the claim. If an error is found, submit a correct claim. If all information was correct on the origin

ng required for dates of service 10/01/2015 and after. Please correct and resubmit claim to the Department for processing. Note: External Cause of Morbidity codes
imary/principal diagnosis.

ng required for dates of service 10/01/2015 and after. Please correct and resubmit claim to the Department for processing.

ng required for dates of service 10/01/2015 and after. Please correct and resubmit claim to the Department for processing.

claim for dates of service prior to 10/01/2015 using ICD-9 codes and a separate claim for dates of service on or after 10/01/2015 using ICD-10 codes.

ng required for dates of service 10/01/2015 and after. Please correct and resubmit claim to the Department for processing.

agnosis either not found or invalid for service through dates on or after 10/01/2015. Correct and resubmit claim to the Department of processing.

received with an External Cause of Morbidity as the primary/principal diagnosis. Review the coding on the rejected claim for correctness. If an incorrect code was re
hould be submitted with the correct code.

130 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ubmitted with an incorrect diagnosis indicator. For dates of service prior to 10/01/2015, ICD-9 diagnosis indicator is required. For dates of service on/after 10/01/201
dicator is required. Please submit a corrected claim.

ontains one of the following errors: Revenue Code 055X or 056X was billed and the Service Through Date is earlier than January 1, 2016; or Revenue Codes 055X
claim, but claim did not contain Revenue Code 0651; or 055X or 056X was billed, but the Patient Status is not equal to 20, 40, or 42; or 055X or 056X was billed in
he derived maximum allowed; or 055X was billed and the claim does not have corresponding G0299 HCPCS code; or 056X was billed and the claim does not have
ng G0155 HCPCS code. Please correct and resubmit.

l error code. The claim contained Revenue Code 0651 and payable days are paid at the higher rate (first 60 days of care). The number of days paid at the higher ra
he paper Remittance Advice for tracking purposes.

Care Authorization on file. Participant had coverage under The County Care Program and a prior authorization is required to bill for services. Please contact County C
61 to obtain a prior authorization, then resubmit claim.

s not affiliated with the County Care Program and cannot bill the Department for services. Please contact County Care at 1-855-444-1661 for assistance with claim.

received for a participant who was enrolled in the Cook County MCCN (County Care) on the date of service. Please contact Cook County MCCN at 1-855-444-1661

ms Only: For a single date of service a claim must contain Revenue Code 0634/0635/0636 and Revenue Code 0821. For a series bill, service through date is greate
date and the claim does not have the same number of service lines for Revenue Code 0821 as the number in Value Code 80. Please check the number of service l
80 and rebill the claim.

A Medicare covered claim was received without a valid exhaust date. The number of non-covered days submitted on the claim is greater than the sum of all occurr
ut there is no exhaust code reported. Valid Medicare exhaust codes include A3, B3, 22, & 25. Correct and resubmit.

MDS Assessment date required for nursing facility. Report Occurrence Code 50 & associated date on claim.

131 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

The participant does not have a LTC segment on file for this provider for the dates of service billed on the claim. Correct claim & resubmit. If the claim submitted is
act a LTC billing consultant at 1-844-528-8444 or 217-782-0545 for assistance.

The claim received contained service from & thru dates that crossed two (2) or more calendar months. This is only allowed when the participant is discharged on th
onth and not deceased. Split claim and resubmit.

The claim contained invalid information. Verify the submitter on claim, statement covers period, and MCO enrollment dates for the recipient. For Developmental Tr
Code 24 (Agency code), Statement From date, Revenue Line units. Correct the claim as needed, then resubmit.

The participant on the claim is not in the allowed age range for the facility. To correct, validate the participant birthdate on the claim and, if necessary, the statemen
ect as needed. If these items are correct on the claim, the rejection is valid and the claim is ineligible for payment.

For Developmental Training only, either the Agency Code (Value code 24) is incorrect on the claim or the code is correct, but the statement covers period is inconsi
d dates on file for Developmental Training . To correct, validate the Agency Code and statement covers period and begin/end date for participant at this Developme
rect as needed and resubmit claim.

The claim was missing either the occurrence span "74" leave of absence period or the revenue code(s) for the leave period(s). Validate these field values. Correct
t.

For Exceptional Care services only, either the recipient ID billed is not enrolled for Exceptional Care services or the Revenue Codes on the claim are incorrect for th
Care services billed. Validate the Service From & Service Thru dates, the Revenue Codes, and the approval for Exceptional care. Correct as needed and resubmi
onsultant at 1-844-528-8444 or 217-782-0545 if there are any problems associated with this edit.

For Developmental Training claims, the claim submitted did not have a Value Code "24" (Agency Code). Validate the Agency Code number assigned to the particip
ntal Training facility and resubmit claim.

The claim billed contained a Medicare payor loop for a participant that does not have Medicare. Validate the Medicare coverage for the recipient. Correct claim as
t.

132 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

The total days on claim do not match the accommodation Revenue Codes billed on the claim. Validate the statement covers period for accuracy and the accommo
des. Correct as needed and resubmit claim.

Either the sum of the Covered and Non-covered Days do not balance with the statement covers period or the number of Coinsurance Days is greater than the num
ys. Validate these values and resubmit corrected claim.

The participant is enrolled in a Medicare Advantage Plan and the claim did not contain a TPL payor loop for the Medicare Advantage Plan (TPL 920). The provider
e Advantage Plan first, then resubmit the claim showing any payment with the TPL 920 code and the appropriate status code.

sing the procedure description. Please correct and resubmit claim to the Department for processing.

ction was received with the Purchase/Rental field blank. Submit a new claim with the Purchase/Rental field completed with a valid value.

ction was received with either the Origin Place or Destination Place field blank. Submit a new claim with both the Origin Place and Destination Place fields complete

ction was received with either blanks or non-numeric values in the COS-Specialty/Subspecialty field. Submit a new claim, completing the entire service section, inclu
COS-Specialty/Subspecialty coding. See Provider Information Sheet for allowable COS-Specialty/Subspecialty.

received with the Type of Bill field blank. Submit a corrected claim. LTC Billing: Correct the Bill Facility or Bill Class field values and resubmit claim.

received without a valid entry in Patient Discharge Status. Patient status must be present for both inpatient and hospice claims. Submit a corrected claim.

as received with the Admission Date field blank. This field is required for inpatient and hospice claims. This field is required for LTC claims, except for Supportive Livi
pmental Training. Submit a corrected claim.

as received with the Admission Hour field blank. This field is required for inpatient claims. Submit a corrected claim ensuring that hour shown is in a 2 ‑digit format. Va
through 23.

133 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ement Covers Period. The claim was received with blanks in the Through field. This field is required for all inpatient and OASA claims. Submit a corrected claim.

s for newborn charges and the Admit Date is equal to the infant's Birth Date the claim must have either Occurrence Code 53 or 58. Occurrence Code 53 also require
charge date. Submit a corrected claim.

Type contains code 4 (Newborn), the newborn's birthdate must be completed. Submit a corrected claim.

e is inconsistent with the Taxonomy Code billed. Correct and resubmit.

al Diagnosis Code is missing from the claim. For dates of service prior to 10-01-2015 refer to ICD-9 for correct coding. For dates of service October 1, 2015 and after
orrect coding. External Cause of Morbidity Codes are not acceptable as the principal diagnosis code.

ission Type. Admission Type must be coded 1, 2, 3, 4 or 5 for inpatient claims. Submit a corrected claim.

nd OASA Claims: If a procedure code is present, a corresponding date must be entered. If a date is present, a procedure code must be present. On OASA claims w
r after July 1, 2005, for each HCPCS code there must be a corresponding service date. Submit a corrected claim.

enue Code. Hospital Billing: A valid room and board revenue code must be shown for an inpatient claim. LTC Billing: Accommodation revenue code required exc
Living Facilities and Developmental Training. Submit a corrected claim.

l Billing: Review Service Units. For the accommodation code for inpatient claims, the number of days must be entered as Service Units. If all days associated with a
tion code are being reported as non-covered days, a numeric zero must be entered for the units. Submit a correct claim. For outpatient series claims, series billable
have service units greater that zero. Hospice Billing: Review Service Units. For revenue codes 651, 655, 656, and 658, the number of days is entered as Service
e 652, the number of hours is entered as Service Units for dates of service prior to January 01, 2007 and for dates of service on or after January 01, 2007 the numb
s is entered as 15 minute increments. For revenue code 657, the number of visits or procedures is entered as Service Units. LTC Billing: Service units required on
tion Revenue Codes. Submit a corrected claim.

enue Code and HCPCS / Rates to determine whether an accommodation rate was entered for each accommodation listed. Insert a decimal where indicated (e.g.13
rrected claim.

134 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ling: Revenue Code(s) and Total Charges; an entry must be made for Total Charge for each revenue code. LTC Billing: Rug score does not require a total charge
have an amount. Submit a corrected claim.

enue Code. Revenue code 0001 for total charges was missing on the claim. Submit a corrected claim.

received with the Total Charges field blank. Submit a new claim with a value in the Total Charges field.

g: The claim received was missing either the Procedure Code or Drug Item number in the Item or Procedure Code field. Submit a new claim with a valid value in eith
e Code field as appropriate. Institutional Billing: Review Revenue Code and Principal Procedure through Other Procedure. For inpatient claims, if an operating r
e is present, claim must contain a corresponding procedure code. For outpatient claims, if the Provider Taxonomy Code billed is other than Outpatient Renal Dialy
Procedure Listing (APL) code must be present. Refer to the "Web Site Resources" tab for a link to the APL. For OASA claims, a procedure code must be present. S
aim.

contains Occurrence Span Code 74, then the claim must contain the number of Non‑Covered Days. Submit a corrected claim.

ence Code value contains the span code of 74, then the From date must be present in MMDDYY format. Submit a corrected claim.

ence Code value contains the span code of 74, then the Through date must be present in MMDDYY format. Submit a corrected claim.

ered Days. The number of Covered Days must be entered on all inpatient, hospice and outpatient series claims. Submit a correct claim.

urrence Code and date. Occurrence code 53 must be followed by the mother’s discharge date.

g: Review the TPL Code field in either the service section or at the bottom of the claim form. An entry in any of the other TPL data fields requires a valid value in this
w claim with correct data. Institutional Billing: Review Prior Payments. If a TPL payment amount is present, the two digit TPL source code must be entered. Pape
n or after May 01, 2008 must be billed on the UB 04 claim form. Pharmacy Billing and LTC Billing: Review prior payments. If a TPL payment amount is present, t
Code must be entered. Submit a corrected claim. Refer to the "Web Site Resources" tab for links to the TPL Resource Code Directory and Pharmacy Benefits Man
urce Code Directory.

135 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

g: Review the Status field in either the service section or at the bottom of the claim form. An entry in the TPL Code field requires a valid value in this field. Submit a
alid values for this field, refer to billing instructions in the appendices of the Chapter 200 handbook applicable to the provider specialty/subspecialty-service being bill
l Billing: If a TPL Source Code is present a TPL Status Code must be entered. Submit a corrected claim. Links to the Department's provider handbooks and the TP
ory can be found on the "Web Site Resources" tab.

l Billing: Review Prior Payment information. If TPL information indicates a valid TPL Status Code of 01, then the TPL payment amount reported must be greater tha
rrected claim.

l 837I and DDE Billing: TPL prior payment Claim Adjudication Date required.

PL Deductible amount was invalid or missing. Please correct the claim with the correct TPL Deduction amount and resubmit the claim for processing.

received with blanks in the Billing Date. Submit a correct claim with the Billing Date entered in the MMDDYY format.

tion claim was received and the vehicle license number was not reported or the license number was invalid.

ure code billed is not covered for MCOs. Please review the claim and rebill with an MCO covered HCPCS Code.

contains Non-covered Days, then the claim must contain Occurrence Span Code 74 with the non-covered date span. Submit a corrected claim.

received for a service which required the Referring Practitioner Number be reported.

ement Covers Period. The From date must be present. Submit a corrected claim.

pecialty/Subspecialties) 25 and 29, the "other" physician NPI must be on the claim. For COS (Specialty/Subspecialties) 20,21,22 and a surgical procedure is on the c
ician NPI is required.

nding Physician. The attending physician identification number must be entered for all claims except when the Taxonomy Code billed is ESRD Treatment (Outpatien
RD). Submit a corrected claim.

136 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ntity was identified on the claim form. The IMPACT system has multiple Pay To entities registered for the provider. Please check payees (Pay To) on the most curre
Sheet. If the information reflected on the Provider Information Sheet is incorrect or out of date, the information must be updated in IMPACT. Do not to resubmit the
r Information Sheet is received verifying that the update to IMPACT has been made in the Legacy MMIS claims processing system. Refer to the "Web Site Resourc
IMPACT system.

submitted with an invalid code as the primary/principal diagnosis code. For dates of service prior to 10-01-2015 refer to ICD-9 coding manual. For dates of service o
refer to ICD-10 coding manual. If the ICD‑9 or ICD-10 code contains a leading alpha character it must be included as part of the diagnosis code. E-codes may not b
principal diagnosis. If an incorrect code was reported, a new claim may be submitted with the correct code.

submitted with an invalid code as the secondary diagnosis code. For dates of service prior to 10-01-2015 refer to ICD-9 coding manual. For dates of service on or a
o ICD-10 coding manual. If the ICD‑9 or ICD-10 code contains a leading alpha character it must be included as part of the diagnosis code. If an incorrect code was re
ay be submitted with the correct code.

submitted with an invalid code as the third diagnosis code. For dates of service prior to 10-01-2015 refer to ICD-9 coding manual. For dates of service on or after 10
10 coding manual. If the ICD‑9 or ICD-10 code contains a leading alpha character it must be included as part of the diagnosis code. If an incorrect code was reporte
e submitted with the correct code.

submitted with an invalid code as the fourth diagnosis code. For dates of service prior to 10-01-2015 refer to ICD-9 coding manual. For dates of service on or after 1
10 coding manual. If the ICD‑9 or ICD-10 code contains a leading alpha character it must be included as part of the diagnosis code. If an incorrect code was reporte
e submitted with the correct code.

submitted with an invalid primary/principal diagnosis code. Refer to medical records to determine the correct diagnosis. For dates of service prior to 10-01-2015 refe
ual. For dates of service on or after 10-01-2015 refer to ICD-10 coding manual. If an incorrect code was reported, a new claim may be submitted with the correct co

submitted with an invalid secondary diagnosis code. Refer to medical records to determine the correct diagnosis. For dates of service prior to 10-01-2015 refer to IC
dates of service on or after 10-01-2015 refer to ICD-10 coding manual. If an incorrect code was reported, a new claim may be submitted with the correct code.

137 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted with an invalid third diagnosis code. Refer to medical records to determine the correct diagnosis. For dates of service prior to 10-01-2015 refer to ICD-9 c
dates of service on or after 10-01-2015 refer to ICD-10 coding manual. If an incorrect code was reported, a new claim may be submitted with the correct code.

submitted with an invalid fourth diagnosis code. Refer to medical records to determine the correct diagnosis. For dates of service prior to 10-01-2015 refer to ICD-9
dates of service on or after 10-01-2015 refer to ICD-10 coding manual. If an incorrect code was reported, a new claim may be submitted with the correct code.

is code received is not covered for the date of service. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not rebill. No
e.

is code received is not covered for the date of service. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not rebill. No
e.

is code received is not covered for the date of service. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not rebill. No
e.

is code received is not covered for the date of service. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not rebill. No
e.

is code received is not covered for the age of the participant. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not reb
n be made.

is code received is not covered for the age of the participant. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not reb
n be made.

is code received is not covered for the age of the participant. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not reb
n be made.

is code received is not covered for the age of the participant. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not reb
n be made.

138 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

is code received is not covered for the gender of the participant. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not
n be made.

is code received is not covered for the gender of the participant. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not
n be made.

is code received is not covered for the gender of the participant. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not
n be made.

is code received is not covered for the gender of the participant. Review the claim and if an error was made, rebill. If no error was made on the original claim, do not
n be made.

eds to submit claim to participant's Care Coordination Plan. Refer to one of the Department's electronic verification systems (MEDI, REV/EDI or AVRS) to identify the
participant is enrolled. Links to the Department's eligibility systems and to a listing of contacts at the Medicaid health plans can be found on the "Web Site Resource

ackaged as a 35 day vial. The Department will not pay for any other Days Supply.

r taxonomy code billed is not one for which the provider is eligible to bill based on the Specialty/Subspecialties selected in IMPACT. Refer to the Provider Information
ategories of Service (Specialty/Subspecialties). If the IMPACT record is incorrect, please update to reflect the correct Specialty/Subspecialties. Do not resubmit the c
r Information Sheet is received verifying that the update to IMPACT has been made in the Legacy MMIS claims processing system. If the IMPACT record is correct,
xonomy code by referring to the Category of Service-Taxonomy Default tables for 837I and 837P found in the Chapter 300 handbook. If an incorrect taxonomy code
axonomy code and resubmit the claim. Refer to "Web Site Resources" tab for links to both the IMPACT system and to the Department's provider handbooks.

received with a COS-Specialty/Subspecialty not selected in the provider's IMPACT record. Please verify accuracy of the Specialty/Subspecialty and, if necessary, u
ord. Do not resubmit the claim until a new Provider Information Sheet is received verifying that the update to IMPACT has been made in the Legacy MMIS claims pr
er to the "Web Site Resources" tab for a link to the IMPACT system.

139 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

lty/Subspecialty billed was not active in the provider's IMPACT record for the date of service billed or the provider has not selected the Specialty/Subspecialty. Pleas
the Specialty/Subspecialty and, if necessary, update the IMPACT record. Do not resubmit the claim until a new Provider Information Sheet is received verifying that
has been made in the Legacy MMIS claims processing system. Refer to the "Web Site Resources" tab for a link to the IMPACT system.

received on a billing document which the provider is not eligible to use based on the provider type (Specialty/Subspecialty) selected in IMPACT. The service(s) mus
opriate form. To identify the correct claim form, refer to the Chapter 200 Handbook applicable to the service being billed. A link to the Department's provider handboo
"Web Site Resources" tab. If additional assistance is needed, please contact a NIPs billing consultant 1-877-782-5565.

received with a provider number not listed in the Department's files. Review claim records to ensure that the correct provider number was submitted. If an error is f
laim using the correct provider number. To enroll, visit the IMPACT provider enrollment page on the Department's Web site. Refer to "Web Site Resources" tab for
tem.
received with a provider name other than the name registered in the IMPACT system for the provider number entered on the billing form. Review the current Provid
Sheet for the correctness of both the provider name and number in the IMPACT system. The provider name submitted on the claim must be entered exactly as it app
Information Sheet. If the information in IMPACT is out of date or incorrect, please update the IMPACT system. Do not resubmit the claim until a new Provider Infor
eived verifying that the update to IMPACT has been made in the Legacy MMIS claims processing system. Refer to the "Web Site Resources" tab for a link to the IMP

iously suspended due to an audit has been rejected. Do not rebill. The provider has been officially notified that their participation in the program has been terminated

or Institutional DDE Billing: A claim was received that contained the hospital’s fee‑for‑service provider number. Resubmit the claim with the appropriate provider n
s submitted on or after May 01, 2008 must be billed on the UB-04 and in accordance with the UB-04 billing instructions.

Revenue Service (IRS) has notified the Department that a lien has been levied against payments made by the Department to the provider number on the claim. All
e been re-directed until the IRS lifts the levy.

entity received on the claim identifies a Pay To entity who was not associated to the provider under IMPACT for the date(s) of service billed. Review the current Prov
Sheet to determine if the desired Pay To entity has been properly registered in IMPACT. If the information is incorrect, please update the IMPACT system. Do not re
new Provider Information Sheet is received verifying that the update to IMPACT has been made in the Legacy MMIS claims processing system. Refer to the "Web S
tab for a link to the IMPACT system.

vice under Department review.

140 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

g: The claim was suspended for special review and the service was then rejected as inappropriate for payment. Do not rebill. Institutional Billing: The provider is d
heir cost report to the Department. No payments will be issued until receipt of the aforementioned report. Please contact a billing consultant at 1-877-782-5565.

as received with the Prescribing Practitioner field blank. A new claim with the missing data included should be submitted.

ot enrolled in the Vaccine Program. The Department does not pay for vaccines that can be obtained for free through the Vaccines for Children Program. Provider ca
s for Children Program to receive these vaccines at no cost. Refer to "Web Site Resource" tab to obtain additional information on the Vaccines for Children Program

y accuracy of enrollment information in IMPACT. If information is incorrect or out of date, please update IMPACT record. Do not submit claims until a new Provider I
eived verifying that the updates have been made in the Legacy MMIS claims processing system. Refer to the "Web Site Resources" tab for a link to the IMPACT sys

as been temporarily suspended for Department review. The final status of the claim will be reported on a future Remittance Advice. Do not rebill.

ment has been ordered to re-direct the provider’s warrants to the IRS because of an outstanding tax levy, wage garnishment, etc.

submitted for a children’s hospital where one of the following apply: 1) the participant was 18 years of age or older on the date of admission, or 2) the participant wa
axonomy code for inpatient psychiatric or for inpatient rehabilitation was reported, or 3) claim was submitted with incorrect principal diagnosis coding, or 4) claim was
ct DRG coding. Review the medical records and the coding on the rejected claim. If an error is found, submit a corrected claim. If assistance is needed, contact a h
ltant at 1-877-782-5565.

submitted with an adult hospital number and the patient is under age 18 on the date of admission and one of the following apply: 1) a General Inpatient Taxonomy C
n the claim and the DRG code is incorrect, or 2) an Outpatient General Taxonomy Code was submitted on the claim and the Principal Diagnosis code is incorrect, or
Renal Dialysis Taxonomy Code was submitted on the claim and the Principal Diagnosis code is incorrect. Review the medical records and the coding on the rejected
d, submit a corrected claim. If assistance is needed, contact a hospital billing consultant at 1-877-782-5565.

an be made only to entities who have a certified W-9 on file with the State Comptroller certified payees. Prior to resubmitting a claim, please ensure the Pay To entity
9 on file with the State Comptroller and is properly enrolled in the Department's IMPACT system.

141 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

as been reviewed by the Department's Peer Review Organization/Quality Improvement Organization (PRO/QIO). It has been determined that a different diagnosis co
tely reflect the services provided. Make the appropriate corrections and rebill a hard copy claim with the PRO/QIO Advisory Notice attached. Refer to the "Web Site
tab for a link to the Department's PRO/QIO.

d by the Department's PRO/QIO. Do not rebill. Claim is not eligible for payment.

received with the Prescribing Practitioner Number of a physician who has been terminated by the Department. Prescriptions from terminated physicians will not be h
ent.

rrect claim indicating the proper Occurrence Code.

received with an Early Intervention Payee designated.

r type listed on the claim is not valid for the procedure code billed.

r hospital's billing consultant at 1-877-782-5565.

received on a billing document which the provider is not eligible to use based on the provider type (Specialty/Subspecialty) selected in IMPACT. The service(s) mus
opriate form. To identify the correct claim form, refer to the Chapter 200 handbook applicable to the provider type/service being billed. A link to the Department's prov
can be found on the "Web Site Resources" tab. If additional assistance is needed, please contact a NIPs billing consultant 1-877-782-5565.

Pay To) submitted on the claim was not valid for the Date of Service (NIPS) or the End Date of Service (Institutional) billed. A default payee from the Provider Inform
report the rejection of the claim. Review the current Provider Information Sheet to determine which payee (Pay To) entity was active on the Date of Service. If the in
or out dated, please update IMPACT. A new Provider Information Sheet will be sent once the IMPACT update has been made in the Legacy MMIS claims processing
"Web Site Resources" tab for a link to the IMPACT system.

r has submitted a claim for services but has an uncollected debt with the Department. Contact a billing consultant at 1-877-782-5565.

received with an NDC which is not valid for a professional service fee reimbursement. Professional service fee reimbursement is only allowed for vaccine administra

142 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received where the Prescriber First Name is missing. Resubmit the claim with this field completed.

received for a Service Professional fee where the NDC does not match a previously paid Service NDC. Verify the correct NDC for the service. Resubmit the Profes
m with the same NDC as the associated paid service.

received where the Primary Care Provider ID was submitted but the Primary Care Provider Last Name field was blank. Resubmit the claim with a value in the Prima
st Name field.

eds to submit claim to participant's Care Coordination Plan. Refer to one of the Department's electronic verification systems (MEDI, REV/EDI or AVRS) to identify the
participant is enrolled. Links to the Department's eligibility systems and to a listing of contacts at the Medicaid health plans can be found on the "Web Site Resource

submitted with a Recipient Identification Number (RIN) that does not match the Department's eligibility files. Please verify eligibility through MEDI or REV/EDI system
aim including the correct RIN. Refer to "Web Site Resources" tab for links to the Department's eligibility systems.

name does not match the Department’s eligibility files for the Recipient Identification Number (RIN) on the claim. Patient name and number must appear exactly as o
d. Please verify eligibility through MEDI or REV/EDI systems. Submit a new claim with correct information. Refer to "Web Site Resources" tab for links to the Depart
tems.

received for a date of service which does not fall within the range of the participant's medical eligibility period. Review patient's records to ensure that the correct Re
n Number (RIN) was used for the dates of service being billed. Please verify eligibility through MEDI or REV/EDI systems. If an error occurred, rebill with the correc
o error occurred, no payment can be made. Refer to "Web Site Resources" tab for links to the Department's eligibility systems.

records reflect that the participant was enrolled in a Managed Care Organization (MCO) on the date of service. Please verify eligibility through MEDI or REV/EDI sy
participant's MCO health plan for reimbursement. Links to the Department's eligibility systems and to a listing of contacts at the Medicaid health plans can be found
esources" tab.

143 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received for a service which is the responsibility of the Long Term Care (LTC) facility to provide. The provider should contact the local Department of Human Service
ame of the LTC facility in which the participant resides. The provider has the responsibility to seek reimbursement from the facility. Neither the Department nor the pa
nt's family) has an obligation for payment.

received for a participant who was in Unmet Spenddown status on the date of service. The participant is not eligible until Spenddown is met. Refer to the Chapter 10
r more information on Spenddown. A link to the Department's provider handbooks can be found on the "Web Site Resources" tab.

submitted for a service or item which requires prior approval, but prior approval was denied. No payment can be made.

g: A claim was submitted for a service which requires prior approval but no prior approval is posted on the Department’s files. A prior approval request should be sub
After receiving prior approval, rebill the service on a new claim. Institutional Billing: Review procedure codes to ensure that the correct procedure was submitted.
contact a UB billing consultant at 1-877-782-5565. CMH Billing: A prior approval is required because the authorization limit has been exceeded. Contact Departme
ental Health contractor for assistance.

received for a service to a participant in a limited coverage program administered by the Department. The procedure is not a covered service for this participant.

submitted for a service which required attachment of Form HFS 1977, Acknowledgment of Receipt of Hysterectomy Information. Either the claim lacked the required
s invalid. If the required form was not submitted with the original claim, submit a new claim with the form attached. Submit both in a Special Handling Envelope (HFS
form was invalid, it will be returned with a copy of the claim and a letter specifying the rejection reason. If the form can be corrected, a new claim must be submitted
d. Submit both documents in a Special Handling Envelope (HFS 2248). Refer to the "Web Site Resources" tab for a link to Medical Forms Request - Paper/Envelo

r number submitted on the claim does not match the Department’s prior approval system. Review the claim and if an error was made, rebill. If no error was made on
t rebill. No payment can be made.

received for a participant with a date of service after their date of death. No payment can be made.

144 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ure Code/Diagnosis/Revenue Code received is not appropriate for the sex of the participant. Refer to provider records to determine if the claim showed the correct re
osis and/or procedure. In addition, check to see whether the correct Recipient Identification Number was sent on the original claim. If an error in the original submitta
w claim which includes the correct information.

ure Code/Diagnosis/Revenue Code received is not appropriate for the age of the participant. Refer to medical records to determine if the claim showed the correct re
osis and/or procedure. In addition, check to see whether the correct Recipient Identification Number was sent on the original claim. If an error in the original submitta
w claim which includes the correct information.

ment is investigating the eligibility of the infant patient reported on the claim. Do not rebill. The final status of the service will be reported on a future Remittance Advic

Spenddown credit was not shown on the claim. Review Form HFS 2432 Split-Billing Transmittal for MANG Spenddown Program. Determine if the information on the
e amount of spenddown shown on the claim are the same. Rebill on a new claim form showing correct information.

received for a newborn that has been determined not eligible for assistance. Do not rebill.

received for a service not billed by the Primary Care Pharmacy identified on the participant's eligibility file. The Primary Care Pharmacy can be verified when checkin
eligibility on MEDI or REV/EDI electronic verification systems. A completed Form HFS 1662 (Primary Care Authorization Form) from the Primary Care Pharmacy au
s not attached to the claim. The service(s) may be rebilled by completing a new paper claim and submitting it in a Special Handling Envelope (Form HFS 2248). A co
662 from the Primary Care Pharmacy must be attached to the claim. Refer to the Chapter 100 handbook for additional information on the Recipient Restriction Prog
tment's eligibility systems, provider handbooks and Medical Forms Request - Paper/Envelopes page can be found on the "Web Site Resources" tab.

145 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted for a service not authorized by the Primary Care Physician (PCP) identified on the participant's eligibility file. The PCP can be verified when checking the
eligibility on MEDI or REV/EDI electronic verification systems. A completed Form HFS 1662 from the PCP authorizing services was not attached to the claim. The se
led by completing a new claim. A completed Form HFS 1662 from the PCP must be attached to the claim. Refer to Topic 106 in the Chapter 100 handbook for addi
Links to the Department's eligibility systems and to provider handbooks can be found on the "Web Site Resources" tab.

records indicate the participant's Category of Assistance has changed from a state funded category to a federally funded category or vice versa. Effective with such
ust be split and submitted as separate interim claims. Contact a UB billing consultant at 1-877-782-5565 for assistance.

received for services provided to a participant institutionalized in a Department of Human Services (DHS) inpatient facility. The provider should contact the DHS faci
ayment.

ment’s records show that the participant was eligible for Part A Medicare coverage on the date of service. The claim submitted did not indicate that the service(s) had
ubmitted to Medicare. The service(s) should be submitted to the Medicare Part A Intermediary for processing, prior to submitting a claim to the Department. If a claim
Medicare but no response was received, contact the Medicare Intermediary to determine the disposition of the claim.

ment’s records show that the participant was eligible for Part B Medicare coverage on the date of service. The claim submitted did not indicate that the service(s) had
ubmitted to Medicare. The service(s) should be submitted to the Medicare Part B Carrier for processing, prior to submitting a claim to the Department. If a claim was
but no response was received, contact the Medicare Carrier to determine the disposition of the claim. NIPS Billing Only: If a claim was submitted to Medicare and
y of the Explanation of Medicare Benefits (EOMB) to the claim when it is rebilled.

submitted for services rendered to a participant who is a member of a Managed Care Organization (MCO) with full service coverage. Do not rebill. Contact the MCO
efer to one of the Department's electronic verification systems (MEDI, REV/EDI or AVRS) to identify the health plan in which the participant is enrolled. Links to the D
tems and to a listing of contacts at the Medicaid health plans can be found on the "Web Site Resources" tab.

service which was billed is restricted for payment to residents of a Long Term Care (LTC) Facility. Department records indicate that the participant was not a resident
he date of service. Review the medical records and the rejected claim to insure that the item or service, the resident, and the date of service were correct. If an error
may be rebilled on a new claim.

146 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

iring a prior approval was received but no corresponding prior approval could be found in the Department’s records. If the provider’s records contain an approved pr
he service, review the claim to ensure that it contains the correct item number, date of service and Recipient Identification Number. If not, submit a new claim form w
ormation. If the provider has not requested a prior approval, or if the prior approval contains incorrect information, contact the Prior Approval Unit for assistance. Co
or the various prior approval areas can be found the Chapter 100 handbook. Refer to the "Web Site Resources" tab for a link to the Department's provider handboo

received with a prior approval which does not cover the date of service. Review records to ensure that the date of service submitted is correct. If the date is incorrec
m to the Department. If the date of service is correct but does not match the date or date range covered in the existing prior approval, contact the Prior Approval Unit
Contact information for the various prior approval areas can be found the Chapter 100 handbook. Refer to the "Web Site Resources" tab for a link to the Departmen

ure code billed is not a valid HCPCS code according to Department files. The service may be rebilled on a new claim form by completing the entire service section us
cedure code.

received with a Level II/III alpha/numeric HCPCS code which is obsolete according to Department files. Refer to the coding source used in preparing bills to ensure
edition. If an incorrect code was used, rebill on a new claim form by completing the entire service section with the correct data. If no error is found, forward a new cla
documenting the source of the rejected code in a Special Handling Envelope (HFS 2248). Refer to the "Web Site Resources" tab for a link to Medical Forms Reque
opes page.

received with a procedure code that is obsolete. Verify that the most recent edition of CPT coding manual is being used. If an incorrect code was used, rebill the ser
rm by completing the entire service section with the correct data. If no error is found, forward a new claim form with the service section completed and a letter docum
e rejected code in a Special Handling Envelope (HFS 2248). Refer to the "Web Site Resources" tab for a link to Medical Forms Request - Paper/Envelopes page.

vider Taxonomy Code billed. When the service is Skilled Care (hospital residing), Exceptional Care (hospital residing) or DD/MI (hospital residing) an authorization fo
he claim. For authorization, contact the Bureau of Long Term Care at 1-844-528-8444. For billing problems, contact a billing consultant at 1-877-782-5565.

as been temporarily suspended for Department review. Do not rebill. The final status of the claim will be reported on a future Remittance Advice.

as been temporarily suspended for Department review. Do not rebill. The final status of the claim will be reported on a future Remittance Advice.

ant had met their Spenddown on the date of service and no HFS 2432 Split-Bill Transmittal for MANG Spenddown Program was attached, or the Recipient Liability A
d not match the amount on the HFS 2432. Submit a correct claim with the HFS 2432 Split-Bill Transmittal for MANG Spenddown Program attached.

147 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

as been temporarily suspended for Department review. Do not rebill. The final status of the claim will be reported on a future Remittance Advice.

ant was a Qualified Medicare Beneficiary (QMB) ONLY participant on the date of service and eligible for Department coverage of Medicare coinsurance and deductib
st be billed to Medicare first.

ment’s records indicate that the participant was covered on a Medicaid Presumptive Eligible (MPE) basis on the date of service. MPE provides coverage only for amb
re such as physician and outpatient services. Other services are not payable. If the participant’s status changes retroactively to full coverage under the Medical Assis
m, verify participant number and procedure codes and submit a new claim.

bmitted is a valid code, but is not reimbursable by the Department for the date of service billed. Review claim data to verify both the NDC and date of service submit
und, submit a new claim with correct data. If there are no errors, do not rebill as no reimbursement can be made. If you have any questions, please contact a pharm
t 1-877-782-5565.

nd Drug Administration has determined this drug to be less than effective for all conditions of use prescribed, recommended or suggested in its labeling. No payment
ESI drugs.

submitted for an adult participant who has coverage under the State Transitional Assistance Program. Adult participants covered under this program are not eligible

verify recipient’s date of birth and admit date that was submitted on the claim. Submit a corrected claim.

Service on the submitted service is on or after the termination date for the NDC as shown on the National Drug Code database. Review the prescription to ensure th
was billed. If questions arise, contact a pharmacy billing consultant at 1-877-782-5565.

the billing provider is found in the IMPACT system. Claim cannot be processed until the billing provider is enrolled through the IMPACT system. Do not resubmit th
vider Information Sheet is generated verifying that the update to IMPACT has been made in the Legacy MMIS claims processing system. Refer to the "Web Site Re
to the IMPACT system.

received with a service date that falls within a period when the participant was in a hospice program. Submit the claim to the responsible hospice. If the hospice den
se the service was not related to the terminal illness, submit a new claim to the Department with the hospice denial notice attached. LTC Billing: Only bill the Depa
covered by the hospice provider.

148 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

g: A claim was received with a hysterectomy procedure code and a diagnosis code which does not indicate the need for a hysterectomy. The medical records for the
viewed to determine whether the use of a hysterectomy procedure code was appropriate. If the procedure code was correct, a new paper claim must be submitted w
diagnosis code. Each submittal of the hysterectomy procedure code must have a HFS Form 1977 Acknowledgment of Receipt of Hysterectomy Information attached
l Billing: If a hysterectomy procedure was performed there must be an accompanying hysterectomy diagnosis, other than the admitting diagnosis, on the claim. A l
s Medical Forms can be found on the "Web Site Resources" tab.

received from a hospice for hospice services but the Department’s records do not reflect that the participant was enrolled in a hospice during the service period bein
S Form 1592 (Notification to HFS of Illinois Medicaid Hospice Benefit-Initial Election Period) to the Department if this has not already been done, and rebill the servi
m is already on file with the Department, review the dates on the claim to ensure they are within the date range on the election form. Changes or corrections to the da
m must be submitted to the Department before the hospice services can be rebilled. A link to the Department's Medical Forms can be found on the "Web Site Resou

received from a hospice for a resident residing in a Long Term Care facility on the date of service, but the Revenue Code of either 656 or 659 for dates of service le
or Revenue Code of either 656 or 658 for dates of service greater than 09/30/2003 was not coded on the claim. Submit a corrected claim.

received with Recipient Identification Number 094334588. This Recipient Identification Number is used for medical transportation services only. Review the particip
ct Recipient Identification Number. Submit a corrected claim.

received for a drug identified on the Department's drug database as being for the treatment of Hemophilia. The Department requires that the pharmacy have on file
f Care Agreement (SOCA). No record was found of the SOCA for the Date of Service.

dling is required on this claim. Please contact a billing consultant at 1-877-782-5565.

r rate is missing or invalid. Please resubmit with the correct provider rate/charge to the Department for reprocessing.

g: If a payment amount appears in the TPL Amount field then a value of 01 must be entered in the TPL Status field. Submit a corrected claim. Institutional Billing: A
s listed on the claim with an incorrect TPL Status Code. Submit a corrected claim. Please refer to the Third Party Liability (TPL) Resource Code Directory or the Pha
nager (PBM) —TPL Resource Code Directory. Links to these directories can be found on the "Web Site Resources" tab.

149 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

was received with a Third Party Liability Status of 01. This indicates a TPL amount greater than zero must be present in the TPL Amount field. Review the copy of t
ecords to determine the results of the TPL adjudication. Submit a new claim showing the correct TPL status or payment amount.

received with a Third Party Liability Status of 07 (adjudication pending) but the TPL date is less than thirty days prior to the date the Department received the claim.
ent to accept a claim with a TPL status of 07, 31 days must have elapsed between the ending date of service and the date of receipt of the claim. The provider shou
ds to determine if TPL adjudication has been completed. If not, then a new claim can be submitted after the 31 days have elapsed.

code for Part A Medicare is 909. The correct code for Part B Medicare is 910. Submit a corrected claim.

as received with a TPL Adjudication Date later than the date the claim was prepared. The provider should review the patient's record to verify whether the TPL Adjudi
al claim preparation date was incorrect. Submit a new claim with corrected information.

received with insufficient Third Party Liability Data in the TPL sections of the claim to properly price the service. Contact a billing consultant at 1-877-782-5565.

de is either missing or invalid. Please review claim and resubmit with the correct TPL code. TPL information can be found on the TPL segment when verifying the pa
ough MEDI or REV/EDI electronic verification systems. If the TPL code originally submitted matches what is on MEDI, please resubmit the claim using 999 as the T
ks to the Department's eligibility systems and to the Third Party Liability (TPL) Resource Code Directory can be found on the "Web Site Resources" tab.

ment’s records indicate that the participant had third party coverage, but no TPL information was reported for this claim. Review participant's TPL information through
electronic verification systems. The claim must be submitted to the third party payer before a new claim, with TPL information, can be submitted to the Department.
s electronic verification systems and to the Third Party Liability (TPL) Resource Code Directory can be found on the "Web Site Resources" tab.

150 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

Code does not match the TPL on the participant's record with the Department. TPL information can be found on the TPL segment when verifying the participant's eli
DI or REV/EDI electronic verification systems. Links to the Department's electronic verification systems and to the Third Party Liability (TPL) Resource Code Director
"Web Site Resources" tab.

was received with an unlisted TPL Code (999) and the name of the TPL payment source was not entered. The service should be rebilled with the appropriate TPL p
cted on the claim. TPL information can be found on the TPL segment when verifying the participant's eligibility through MEDI or REV/EDI electronic verification syste
tment's electronic verification systems and to the Third Party Liability (TPL) Resource Code Directory can be found on the "Web Site Resources" tab.

nal claim was received with status code 10 and a Prior Payment amount greater that zero. Review copy of submitted claim to ensure correct status code is used or r
yment amount and insert the Medicare deductible. Submit a corrected claim.

received with a TPL status of 07, but the TPL date on the claim is less than 31 days prior to the date the Department received the claim. There must be 31 days from
ce and date of receipt by the Department. Submit new claim after 31 days have elapsed.

authorized for pregnancy related services to a participant with TPL coverage. Department will contact insurance carrier. No action required. Message for information

authorized for preventative services to a patient with TPL coverage. Department will contact insurance carrier. No action required. Message for information only.

ore than the total charges. Please review TPL payment for accuracy.

g: A claim was received for a participant covered by third party insurance in addition to Medicare B, but no TPL information was submitted with the crossover claim. T
be billed as a secondary payer after Medicare B has approved the charges. If the third party makes payment and an unpaid amount remains, submit a claim form w
OMB and a TPL EOB verifying TPL information. If the third party makes no payment or no liability is in force on the date of service, submit documentation of this fact
OMB with the claim. Institutional Billing: A claim was received for a participant covered by third party insurance in addition to Medicare Part A and or Medicare Part
PL information was submitted on the claim. The third party should be billed and prior payment information is to be reported in addition to Medicare payment informati
claim.

151 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

s a Medicare crossover claim and TPL code 909 (inpatient) or 910 (outpatient) is present, then the first characters of the payer line must be either Medicare or code

st bill Third Party Liability.

Crossover claim was received for a participant and there was TPL information (TPL Code 910) reported at the claim level only. If the TPL information is reported at th
e Service Line Level, the Claim Level TPL must equal the total of the Service Line Level TPL.

ant is eligible on the date of service and has other active pharmacy insurance on file. The claim was received with TPL data such that the Usual & Customary amoun
or equal to $20.00 and either the TPL Amount was less than or equal to $1.00 or the claim is coded as claim not covered by other insurance or the claim is coded a
no payment collected. Verify that the TPL coverage is correct. If correct, a prior approval request must be submitted.

l billing: review payer information. There should be no prior payment and/or TPL code across from the Illinois Medicaid line. Correct and submit a new claim.

Crossover claim was received for a participant and the Provider Charge/Allowed Amount was zero or blank.

Crossover claim was received for a participant and there was a service section that was blank or zero for both the coinsurance and deductible fields.

as been suspended for Department review. The final status will be reported on a future Remittance Advice.

were received, both submitted by encounter clinics, for the same recipient and modifier GT was reported. If the Originating Site is an encounter clinic, the Distant Site
r clinic may not seek reimbursement from the Department for their services. The Originating Site encounter clinic is responsible for reimbursing the Distant Site enco

received for a provider that is not eligible to seek reimbursement as a Telehealth Distant Site provider. Physicians, podiatrists, APNs, ERCs, FQHCs or RHCs are th
gible to seek reimbursement as a Distant Site provider. If an error occurred, rebill with the correct information. If no error occurred, no payment can be made.

152 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received for a provider that is not eligible to seek reimbursement as a Telehealth Originating Site provider. physicians, podiatrists, local health departments, commun
rs, outpatient hospitals, ERCs, FQHCs and RHCs are the only providers eligible to seek reimbursement as an Originating Site provider. If an error occurred, rebill wi
mation. If no error occurred, no payment can be made.

received for a Telehealth service rendered by a Distant Site provider in an encounter clinic setting or a hospital with a place of service other than outpatient. Individu
k reimbursement for Telehealth services rendered in an encounter clinic setting. The clinic is responsible for seeking reimbursement as appropriate. If an error occur
ect information. If no error occurred, no payment can be made.

received for a provider who does not have proof of completion of a psychiatric residency entered on the IMPACT system. If the provider is a psychiatrist who has co
esidency, please update the information in IMPACT to reflect the required certification. Do not resubmit the claim until a new Provider Information Sheet is received v
ate to IMPACT has been made in the Legacy MMIS claims processing system. Refer to the Website Resources tab for link to the IMPACT system. If the provider do
ate certification, payment cannot be made by the Department. If the IMPACT record is correct, please contact Provider Enrollment Services at 1-877-782-5565 for a

received for a Telehealth service rendered by an Originating Site provider in an encounter clinic setting or a hospital with a place of service other than outpatient. Ind
ay not seek reimbursement for Telehealth services rendered in an encounter clinic setting. The clinic is responsible for seeking reimbursement as appropriate. If an e
bill with the correct information. If no error occurred, no payment can be made.

ing billed is a therapeutic duplicate of a drug previously paid for this participant. Please review data on claim for accuracy. If the data was submitted in error, correct
n error and resubmit. If no error was found, provider should request a Refill-Too-Soon (RTS) override if clinical justification exists. The claim can be resubmitted if the
lease contact a pharmacy billing consultant at 1-877-782-5565 for assistance if needed.

patient claim was received lacking a required entry in Condition Codes. Condition code C1 or C3 must be present. Submit a corrected claim.

unit exempt from DRG payment methodology has submitted an interim claim for a period of less than 30 days. Rebill for 30 days of service or more. Note: Interim c
for hospital stays subject to DRG payment methodology.

received with a blank or with non-numeric values in the New/Refill field. Submit a new claim with the New/Refill field completed to reflect the correct dispensing of th

153 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

value in the New/Refill Number field is greater than the number of refills authorized. If additional refills are needed, a new prescription is required.

received with a blank or with non-numeric values in the Days Supply field. Submit a new claim with the Days Supply field completed to reflect the correct dispensing

received with a value in the Days Supply field which exceeds the Department’s maximum quantity allowed for the particular drug. Normally, a one month supply of th
d at one time. Exceptions to this rule are granted to the following Specific Therapeutic Classes: oral contraceptives, inhalers or prenatal vitamins. For further assista
consultant at 1-877-782-5565.

received with a value in the Dispensed as Written field that was blank, contained non-numeric characters or contained a value other than 01 through 06 or 09. Resu
e correct value.

received with a value in the Date RX Written field that was blank or contained non-numeric characters or was not in the MMDDYY format. Resubmit the claim with t

received with a value in the Date of Service field that precedes the date in the Date RX Written field. Resubmit the claim with the correct values.

received with a value in the Compound Code field that was blank or contained a numeric value that was not between 0 and 2. Resubmit the claim with the correct v

equested prior to the use of a specific quantity of the drug. If a valid reason exists for an early refill contact a consulting pharmacist at 1-877-782-5565.

submitted on which Covered Days contained either a blank or non-numeric characters. The number of series days for which outpatient services were provided must
Covered Days. Resubmit the claim with valid values.

submitted on which Covered Days exceeded the number of days indicated in the Statement Covers Period. Submit a corrected claim.

ys contains a number that is greater than the calculated sum of "units" in Service Units for the series billable Revenue Code. Submit a corrected claim.

154 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

eries bills cannot contain procedures from more than one Ambulatory Procedure Listing (APL) group. Contact a hospital billing consultant at 1-877-782-5565 for ass
"Web Site Resources" tab for a link to the APL.

overs Period contains more days than allowed. A maximum of 31 days may be billed on one series outpatient claim. Submit a corrected claim. If necessary, submit m
nt series claim, of no more than 31 days each.

s must contain at least one series billable Revenue Code. Review the medical record and submit a corrected claim.

must contain at least one Ambulatory Procedure Listing (APL) procedure which has been approved for series bills. Review the medical record and submit a corrected
"Web Site Resources" tab for a link to the APL.

refill claim was received for a participant shown in the Department’s records as residing in a Long Term Care facility on the Date of Service. A refill was requested pr
cific quantity of this drug or a specific quantity of this drug plus the prescribed quantities of like drugs exceeds the Department’s Monthly Maximum Quantity. If a vali
early refill, contact a consulting pharmacist at 1-877-782-5565.

sis Code was not valid for the date of service. For dates of service prior to 10-01-2015 refer to ICD-9 coding manual. For dates of service on or after 10-01-2015 refe
ual. Submit a correct claim.

n in Occurrence Span are not within Statement Covers Period. Review the medical record and submit a corrected claim.

n in Occurrence Code (Occurrence Span) overlap each other. Review the medical record and submit a corrected claim.

vices for recipient with Medicare Part A are not billable to the Department.

aim was received where the number of days represented by the Total Number of Units of all 659 Revenue Codes for dates of service less than 10/01/2003 or 658 Re
ates of service greater than 09/30/2003 is greater than the number of days that the patient resided in a Long Term Care facility. Review the medical record and subm
aim.

n was received with the same RX number and the same Date of Service as a previously paid prescription for a different patient. Review the patient’s file to ensure th
mation is being submitted. Submit a correct claim.

155 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

tion received matches an electronically submitted prescription which is pending payment, but which has not yet appeared on a Remittance Advice. Payment for the
l be reported on a future Remittance Advice. Do not rebill.

tion was received with the same RX number, same Recipient Identification Number and the same Date of Service as a previously paid service, but with a different N
NDC). Review the patient’s file to determine which NDC was dispensed. If the previously paid service was incorrect, submit an adjustment to void that claim and the
correct NDC.

ment’s Long Term Care (LTC) records do not indicate a bed reserve type “41". This type of bed reserve permits the LTC room and board payments to be directed to
ntact a UB billing consultant at 1-877-782-5565 for assistance.

received which contains an unallowable combination of Revenue Codes. When billing outpatient ESRD, revenue codes 82X, 83X or, 88X may not be shown with rev
r 851 on the same claim. Series claims for renal dialysis must be split if the patient received more than one type of dialysis during the treatment span.

received for a service that a Nurse Practitioner is not allowed to bill. Review the patient’s record to determine whether the correct procedure code was submitted. If
ode was submitted, rebill on a new claim using the correct information.

received for a service that is covered only for children, but the patient was over the age of 21 on the date of service. Refer to the records to ensure that the correct R
n Number was used. If an error is found, submit a new claim which includes the correct information.

crossover claim was received from an ASTC (Ambulatory Surgical Treatment Center) on a UB/837I/Institutional DDE. Bill the service to Medicare on a CMS 1500 He
laim Form.

mbulatory Surgical Treatment Center) billed for a procedure on a Form HFS 2360 that should have been billed on a UB/837I/Institutional DDE. Resubmit the claim o
ce.

received for services that cannot be billed by this provider specialty/subspecialty. For further assistance, contact a billing consultant at 1-877-782-5565.

received from an optometrist for a service that is allowed but the primary diagnosis code is not logical for the procedure. Refer to the records to ensure that the corr
de was used. If an error is found, submit a new claim which includes the correct information.

156 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

claims, the Service Units for Revenue Codes 0651, 0655, 0656, and 0657 cannot exceed the covered days. Each Revenue Code must be compared to the covered

Crossover claim for anesthesia services was submitted with either a missing or an invalid modifier on the claim. Submit a new claim with correct information.

Type of Bill is incorrect for an Ambulatory Surgical Treatment Center (ASTC) or the Type of Bill indicates ASTC but the billing provider is not an ASTC. Submit a corr

n was received for an NDC that is missing certain data on the Department’s National Drug Code database. This data is required to determine the correct reimburse
ontact a pharmacy consultant at 1-877-782-5565.

nt ESRD claims, Revenue Code 0636 requires a HCPCS code.

when a value code of 68 is present, there must be a charge for Epogen (Revenue Code 634 or 635) on the claim. Review the medical record and submit a corrected

for home daily dialysis revenue codes 841 or 851, the sum of Covered Days plus Noncovered Days must equal the Statement Covers Period. Review the medical
rected claim.

received for a date of service prior to 10-01-2015 with an invalid Admitting Diagnosis Code. Review the patient's medical record to determine correct diagnosis code
ior to 10-01-2015, refer to the ICD-9 coding manual. Submit a corrected claim.

received for a date of service prior to 10-01-2015 with an invalid E‑Code (diagnosis). Review the patient's record and ICD-9 coding manual to determine the correct
ubmit a corrected claim.

received for a date of service prior to 10-01-2015 with an invalid Admitting Diagnosis Code. Review the patient's record to determine the correct diagnosis code. For
to 10-01-2015, refer to the ICD-9 coding manual. Submit a corrected claim.

157 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received with an E-Code as the Principal Diagnosis Code. E-codes are not acceptable as a principal diagnosis code. Review the medical record to determine the ap
gnosis. Submit a corrected claim.

received with an invalid E-code (diagnosis) in one of the External Cause of Injury (ECI) Code fields. For dates of service prior to 10-01-2015 refer to ICD-9 coding m
rrected claim.

g Diagnosis Code FL76 was missing on the submitted claim. This is a required field on inpatient claims and LTC claims, except for Supportive Living Facilities and
ntal Training.

for inpatient psychiatric services (psychiatric taxonomy code), there must be a diagnosis code. Review the medical record to determine the correct diagnosis code a
ode. For dates of service prior to 10-01-2015, refer to the ICD-9 coding manual. For dates of service on or after 10-01-2015, refer to the ICD-10 coding manual. Subm
aim.

dition Codes. A condition code of A7, A8 or 96 is required if an abortion procedure is listed. Review the medical record and submit a corrected claim.

received with an illogical combination of Condition Codes and Procedure Codes. If a Condition Code of AA, AB, AD or AE is listed, an abortion procedure code is req
medical record to determine which entry is in error and submit a corrected claim.

received which had more than one abortion Condition Code listed. Review the medical record and select the single most appropriate code. Submit a corrected claim

received for hospice services, but Department records do not indicate that the participant was enrolled by the billing hospice on the date(s) of service. If the claim is
S Form 1592 (Notification to HFS of Illinois Medicaid Hospice Benefit - Initial Election Period) . Allow two weeks for Department processing before submitting a new
original claim was incorrect, submit a correct claim. A link to the Department's Medical Forms can be found on the "Web Site Resources" tab.

eries claims that cross July 01, 2004 must be split. Does not apply to outpatient ERSD claims.

158 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

Code 74 non-covered date span cannot be the same as the statement covers period.

SRD claims for recipients on the State Chronic Renal Disease Program cannot cross calendar months.

submitted with Revenue Codes 0651 and/or 0652, without Value Code 61 or the code was 61 with no valid CBSA code for where the service was provided. For claim
vice after 12/31/2007, Revenue Codes 0655 and 0656 require Value Code G8 with the CBSA code where the inpatient service was provided. Submit a corrected cla
m was correctly coded, contact a UB billing consultant at 1-877-782-5565.

received for a DCFS screening, but the patient Recipient Identification Number (RIN) did not belong to a DCFS ward. Review the patient’s eligibility records. If the p
submit a corrected claim with the correct RIN.

received for a DCFS screening, but the provider has not been authorized to provide these services. Contact a UB billing consultant at 1-877-782-5565 for assistanc

received for a category of service (Specialty/Subspecialty) that was not billable by a Nurse Practitioner/Midwife.

received with a value in the Type of Service/Role Code field which is identified as illogical for the procedure code. Rebill with correct information. For assistance, co
ltant at 1-877-782-5565.

received with an invalid code in Field 23C (Sterilization/Abortion) on the HFS 2360. Refer to HFS 2360 billing instructions for the correct coding and rebill the service

received with either a blank or a code that is not a valid value for the place of service. Rebill on a new claim by completing the entire service section including the ap
vice code.

received with either a blank or non-numeric value in the service line Charges/Provider Charge field. Rebill on a new claim by completing the entire service section in
ovider Charge field.

received with either a blank or non-numeric value in the Balance Due field. Rebill on a new claim by completing the entire service section including the Balance Due

159 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received with either blanks or a non-numeric value in the “# Sects” field. Rebill on a new claim with the #Sects field completed. Count all non-deleted service lines.

received with either a blank or an invalid entry in the Modifying Units field for an anesthesia service. Rebill on a new claim by completing the entire service section.

received with a blank in the Referring/Ordering Practitioner Number field. Submit a new claim with the Referring/Ordering Practitioner Number field completed.

received with either a blank or an invalid value in the Purchase/Rental Code field. Rebill on a new claim with a valid value in this field.

received with an invalid origin or destination modifier. If an error occurred, rebill with the correct origin or destination modifier. If no error occurred, no payment can b

e payment amount (Total Deductions field) is not numeric. This error is only created as a result of an error in the data entry of Department generated data. Resubmi
sover documentation for reprocessing.

g: The cash deductible amount is not numeric. This error is only created as a result of an error in the data entry of Department generated data. Resubmit the original
on for reprocessing. Institutional Billing: Review Medicare deductible amount. This field must be numeric. Submit a corrected claim.

g: The coinsurance amount, as entered, was not numeric. This error is only created as a result of an error in the data entry of Department generated data. Resubmit
ocumentation for reprocessing. Institutional Billing: Review Medicare Co-insurance amount. This field must be numeric. Submit a corrected claim.

g: The Medicare Adjudication date was not completed in the MMDDYY format. This error is only created as a result of an error in the data entry of Department gener
e original crossover documentation for reprocessing.

ment field on the Medicare crossover claim was not completed as “Yes”. The provider is required to accept assignment on claims billed to Medicare. Otherwise the D
me any patient liability for coinsurance and/or deductible. The original claim submitted to the Department should be reviewed. If a processing error occurred or there
circumstances as to why the provider failed to accept assignment with Medicare, resubmit the crossover claim with a letter of explanation in a Special Handling Enve
er to the "Web Site Resources" tab for a link to Medical Forms Request - Paper/Envelopes page.
160 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

g message on an encounter claim. There is no action required by the provider. MCO should ensure that plan code in TPL field is correct on future MCO encounter cla

records reflect that the participant was not enrolled in the managed care plan listed on the claim. Review patient's records to ensure that the correct Recipient Identi
s used for the dates of service being billed. If an error occurred, rebill with the correct information. If no error occurred, no payment can be made.

g message on an encounter claim. There is no action required by the provider. MCO should ensure that plan code in TPL field is correct on future MCO encounter cla

received with blanks in the field used to identify the origin of the trip. Rebill the service section on a new claim.

received with blanks in the field used to identify the destination of the trip. Rebill the service section on a new claim.

received with a non-numeric entry in the Unit/Miles field. Rebill the service section on a new claim.

received with the Destination Time field either blank or containing a non-numeric value or a value which was not in the HHMM format. Rebill the service section on a
tination Time field correctly filled in.

e deductible submitted on the claim exceeds the maximum amount for the year which is being billed. Submit a corrected claim.

e co‑insurance amount submitted on the claim exceeds the maximum amount for the year which is being billed. Submit a corrected claim.

received which contained blank values in either in the Medicare Deductible or Medicare Co‑insurance amounts for this Medicare/Medicaid crossover claim. Submit a

ent Medicare/Medicaid crossover claim with a Taxonomy code for Outpatient Psychiatric Clinic Services Type ‘A’, Outpatient Psychiatric Clinic Services Type ‘B’ or O
habilitation Clinic Services has a number of units in Revenue Code 0001 that is greater than the difference between the Begin and End service dates. Submit a corre

cal characters were contained in Service Units for the number of departments visited for a Medicare/Medicaid crossover claim. Submit a corrected claim.

as been temporarily suspended for Department review. Do not rebill. The final status of the claim will be reported on a future Remittance Advice.

161 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

of renal dialysis services billed exceeds the number of treatments allowed for the service period. Review the medical record and submit a corrected claim. If the num
s services and the service period on the original claim are correct, contact a billing consultant at 1-877-782-5565 for assistance.

received on which the Medicare Co‑insurance amount billed is greater than the Medicare Payment amount. Submit a corrected claim.

received on which the Medicare Deductible amount billed exceeds the Medicare deductible for that year. Submit a corrected claim.

l Charge; Medicare Deductible/Co-insurance and Medicare Payment. The amount Medicare allowed for the claim exceeds the total charges for the services. If amou
r, submit a correct claim.

been rejected for review by the Bureau of Medicaid Integrity.

ment will only allow one initial office visit per patient per physician. Review the original billing and patient files to ensure that the correct provider and participant numb
n error was made rebill with the correct data. If no error was made, rebill the service using a procedure code for a visit for an established patient.

submitted for an initial or confirmatory consultation after payment had previously been made to the same physician for an initial or confirmatory consultation, or a cla
r a follow‑up consultation without documentation. Refer to Chapter 200 handbook applicable to the provider/service being billed for policy on consultation services. I
firmatory consultation was done at the request of the attending physician, rebill on a new claim attaching a copy of the consultation report. When the patient's condit
ne follow‑up consultation, service(s) may be rebilled with a copy of the Hospital Discharge Summary. Submit the documents in a Special Handling Envelope (HFS 22
tment's provider handbooks and to Medical Forms Request - Paper/Envelopes page can be found on the "Web Site Resources" tab.

162 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted for hospital care paid to another physician for the same patient on the same date of service. Initial Hospital Care: Only one admitting practitioner will be
al visit for a single hospital stay. Documentation may be submitted which includes the name of the admitting physician and the comprehensive history and physical e
he time of the admission. Submit the documents in a Special Handling Envelope (HFS 2248). Hospital Visit: Payment is not routinely allowed for daily hospital visi
ysician. Refer to Chapter 200 handbook for practitioners for policy regarding concurrent care. If the patient's condition necessitates concurrent care, the physician m
nsideration by rebilling the service on a new claim and attaching a copy of the Hospital Discharge Summary. Submit the documents in a Special Handling Envelope (
Department's provider handbooks and to the Medical Forms Request - Paper/Envelopes page can be found on the "Web Site Resources" tab.

s submitted for a service not supported by medical documentation or for a procedure/visit considered a part of the surgical service package. For example: hospital
ng major surgery during the thirty (30) day post-operative period, or a follow‑up hospital or office visit on the day of a minor diagnostic or therapeutic procedure, or a
onsidered an inherent part of another procedure and/or an "incidental" procedure. Refer to Chapter 200 handbook for practitioners for policy relative to surgery. If the
t the patient's condition required the additional service, he/she may seek payment by rebilling the service on a new claim with supporting medical documentation. If t
on, the provider may rebill on a new claim with a copy of the consultation report attached. If the attending physician is submitting post ‑operative visit charges for an u
rvice, attach a statement on the physician's letterhead explaining the nature of the injury or illness and a copy of the Admission History and Physical and the Hospita
ubmit the documents in a Special Handling Envelope (HFS 2248). Links to the Department's provider handbooks and to Medical Forms Request - Paper/Envelopes
the "Web Site Resources" tab.

submitted for a procedure/visit/consultation which is not allowed in combination with other billed/paid obstetrical services, or a claim was submitted for a delivery or
ection) which was previously paid to the same or a different physician. Refer to Chapter 200 handbook for practitioners for policy relative to maternity care. Review a
m and medical records to determine if the correct information was shown (procedure code, date of service, participant name and number, delivering doctor/surgeon'
vice code). If an error is found, rebill on a new claim with the correct data. In some cases, payment records must be reviewed to determine if the claim is being reject
usly paid under another service date or procedure code. For example, a C-section was performed but a vaginal delivery was billed in error and paid. If payment has
an incorrect procedure code or service date, submit an adjustment. Refer to the Chapter 100 Handbook, General Appendix 2 for instructions on adjustments. If pay
use another provider has already been paid for the delivery or C-section, but the medical records verify that the delivery/C ‑section was actually done by the provider
claim, rebill on a new claim and attach a copy of the Delivery Room Record or Operative Report and a brief narrative explanation for the resubmittal. Submit the do
andling Envelope (HFS 2248). If the original claim contained correct information and the provider believes the service should be allowed as a separate charge, subm
eration by rebilling the service on a new claim with a statement on the provider's letterhead documenting the need for the service and include copies of any pertinent
bmit the documents in a Special Handling Envelope (HFS 2248). Links to the Department's provider handbooks and to Medical Forms Request - Paper/Envelopes p
"Web Site Resources" tab.

163 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted which contains illogical information, when compared with another procedure which was already paid. For example: 1) a claim was submitted for a previou
cedure which can only be performed once, e.g., appendectomy, cholecystectomy or circumcision or; a claim was submitted for a "partial" procedure for a service dat
r than the service date for a paid "complete" procedure, such as a salpingectomy or oophorectomy with or after a complete hysterectomy or; a claim was submitted
r a hysterectomy or; a claim was submitted for a "complete" procedure for a service date that is the same or before the service date for a billed/paid "partial" procedu
ectomy before a subtotal thyroidectomy. Review the patient's medical records and a copy of the rejected claim to determine if the correct procedure code, service da
ame and number were shown. If incorrect information was shown on the original claim, rebill on a new claim with the correct data. If correct information was shown o
m, the service should be rebilled on a new claim with a copy of the Operative Report or Delivery Room Record or other appropriate medical records to document the
ment will determine if the previously paid service was paid in error. Submit the documents in a Special Handling Envelope (HFS 2248). Refer to the "Web Site Resou
Medical Forms Request - Paper/Envelopes page.

submitted for a component part of another laboratory panel/test paid for the same service date. Review the claim information and the patient's medical records to de
rocedure code and date of service were shown. If either was incorrect, rebill on a new claim with the correct data. If the information on the original claim was correct
one at the same time of the day, do not rebill as no payment can be made. If the laboratory procedure was done at a separate time on the same day, the provider m
onsideration by rebilling on a new claim. Copies of Lab Test Reports for all services billed for the date of service in question must be attached. Submit the document
dling Envelope (HFS 2248). Refer to the "Web Site Resources" tab for a link to Medical Forms Request - Paper/Envelopes page.

submitted for a component part of another x‑ray procedure paid for the same service date. Review a copy of the claim and the patient's medical record to determine
rocedure code and date of service were shown. If either was incorrect, rebill on a new claim with the correct data. If all the information on the original claim was corr
done at the same time of the day, do not rebill as no payment can be made. If the x ‑ray procedure was done at a separate time on the same day due to the nature
ry/illness, the provider may seek payment reconsideration by rebilling the service on a new claim. Copies of Radiology Reports for all x ‑ray services billed for the da
must be attached. Submit the documents in a Special Handling Envelope (HFS 2248). Refer to the "Web Site Resources" tab for a link to Medical Forms Request -
opes page.

164 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted for an item that was previously paid and which is restricted for quantity or frequency or total quantity allowed within a given period. Refer to Chapter 200
n the type of item being billed. Refer to "Web Site Resources" tab for a link to the Department's provider handbooks. If further assistance is needed, contact a billing
2-5565.

s been made to the same or to a different provider for a psychiatric service on this service date. The Department allows one psychiatric service per patient per day. E
ulsive Therapy (ECT) is allowed in addition to any other psychiatric service.

xygen was made within less than a month from the most recent paid oxygen claim. If the reason the claim is being submitted so soon is that the patient died or was
Term Care facility prior to the end of the month, a written explanation of the reason for the billing must accompany the claim. Submit the documents in a Special Ha
FS 2248). Refer to the "Web Site Resources" tab for a link to Medical Forms Request - Paper/Envelopes page.

ms were submitted by the same or different providers for anesthesia services for the same date of service. Payment is allowed for only one anesthesia service per o
e code for the major surgical procedure is to be billed and the total anesthesia time shown in Field 24F (Days or Units). Review a copy of the claim and the Anesthes
if the date of service shown on the rejected claim was correct or if multiple surgery codes were billed for the same date of service. If the surgery date or any other in
ed claim was incorrect, the service should be rebilled on a new claim with the correct data. If multiple surgery codes were billed for the same operative session and
or one, but the total anesthesia administration time exceeded the time shown on the claim for the paid service, an Adjustment Form HFS 2292 should be submitted.
in the Chapter 100 handbook for instructions on preparing adjustments. If surgeries were done at separate times on the same day, the rejected service should be re
ith copies of both Anesthesia Records and a brief narrative explanation. Submit the documents in a Special Handling Envelope (HFS 2248). If payment was denied
vider has already been paid for the anesthesia administration, but the medical records verify that the service was actually delivered by the provider shown on the reje
should be rebilled and a copy of the Anesthesia Record attached. Submit the documents in a Special Handling Envelope (HFS 2248). Refer to the "Web Site Resour
Department's provider handbooks and the Medical Forms Request - Paper/Envelopes page.

165 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

s been made to this provider for a visit or consultation on this service date under a different procedure code. Payment is not routinely allowed for multiple visits on th
. Review the patient's medical record to determine whether the correct information (procedure code, date of service, etc.) was submitted on the original claim. If any
ct, rebill on a new claim. If the rejected visit was for a different time of day than the previously paid visit, the provider may seek payment reconsideration by rebilling o
ative explanation of the medical necessity for the service must be attached. Submit the documents in a Special Handling Envelope (HFS 2248). Refer to the "Web S
tab for a link to Medical Forms Request - Paper/Envelopes page.

submitted for a procedure/visit that was considered part of multiple other procedures.

ds screening visit or additional health exam was previously paid for the date of service shown. Review a copy of the rejected claim and medical records to determine
mation was shown on the claim (procedure code, service date, patient name, etc.). If any of the data was incorrect, rebill on a new claim. If all information was corre
m, do not rebill. Refer to payment records to determine which previously paid service caused the rejection.

s previously made for a Healthy Kids service (screening visit, follow‑up visit, make‑up visit) or for an office visit code for the same date of service. Payment is allowe
eening or exam for a participant on a single service date. The provider should review a copy of the rejected claim and medical records to determine if the correct inf
on the claim (procedure code, service date, patient name, etc.). If any of the data was incorrect, rebill on a new claim. If all information was correct on the original cla
to payment records to determine which previously paid service caused the rejection.

received for an immunization code of a previously paid claim. Review a copy of the rejected claim and medical records to determine whether the correct information
(procedure code, service date, participant, name, etc.). If the information was incorrect, rebill on a new claim. If all information was correct on the original claim, do
ment records to determine which previously paid service caused the rejection.

thy Kids immunizations are limited to one occurrence each in a participant's lifetime. Payment has previously been made for this immunization. Review a copy of th
edical records to determine whether the correct information was shown on the claim (procedure code, service date, patient name, etc.). If any of the data was incorr
If all information was correct on the original claim, do not rebill.

166 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

received for an immunization code which includes one or more components of a previously paid claim for a Measles/Mumps/Rubella immunization. Review a copy o
m and medical records to determine whether the correct information was shown on the claim (procedure code, service date, participant, name, etc.). If the informatio
bill on a new claim. If all information was correct on the original claim, do not rebill. Refer to payment records to determine which previously paid service caused the

the Sickle Cell Test is limited to one occurrence in a participant's lifetime for the same physician. Review the rejected claim to determine whether all the information
n error is found, rebill with a new claim. If no error is found, do not rebill.

received for one or more days of renal dialysis that had previously been paid. One of the following applies: the Department previously paid the same or a different p
e on the same date of service or; the claim was for monthly services during a period for which one or more daily services had previously been paid to the same or a
the claim was for daily services during a period for which a monthly service had previously been paid to the same or a different provider. The provider should review
claim and medical records to determine whether the correct information was shown on the claim (procedure code, service date, Recipient Identification Number, etc
s incorrect, rebill on a new claim. If all information was correct on the original claim, do not rebill. Refer to payment records to determine which previously paid servic
. If additional assistance is required contact a billing consultant at 1-877-782-5565.

r billed for a component procedure code when a complete procedure code had been paid previously. The provider should review a copy of the rejected claim and me
etermine whether the correct information was shown on the claim (procedure code, service date, Recipient Identification Number, etc.). If any of the data was incorre
If all information was correct on the original claim, do not rebill. Refer to payment records to determine which previously paid service caused the rejection.

received for a procedure that had previously been paid for the same date of service.

r was previously paid for a component of the all‑inclusive procedure code billed. Review a copy of the rejected claim and medical records to determine whether the c
was shown on the claim (procedure code, service date, Recipient Identification Number). If any of the data was incorrect, rebill on a new claim. If all information was
claim, do not rebill. Refer to payment records to determine which previously paid service caused the rejection.

f service and procedure code billed. If any of the data is incorrect, rebill on a new claim. If all information is correct on the original claim, do not rebill.

re submitted for both a dispensing fee and a service fee for the same date of service. Do not rebill. The Department does not allow payment for both a dispensing fe
or the same date of service.

167 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ubmitted in field 24F (Days or Units) for the anesthesia service exceeds the Department’s maximum allowable quantity of 480 minutes (8 hours). If the anesthesia tim
xceeded the Department’s maximum allowable, the service may be rebilled with a copy of the anesthesia record attached. Submit the documents in a Special Handl
FS 2248). Refer to the "Web Site Resources" tab for a link to Medical Forms Request - Paper/Envelopes page.

ubmitted in field 24F (Days or Units) for the number of tests performed for the Procedure Code identified exceeds the Department’s standard. The physician should r
medical documentation to support number of tests billed. Submit the documents in a Special Handling Envelope (HFS 2248). Refer to the "Web Site Resources" ta
orms Request - Paper/Envelopes page.

ubmitted in field 24F (Days or Units) for the surgical procedure exceeds the Department’s maximum allowable quantity of 480 minutes (8 hours) for an Assistant Surg
be rebilled with a copy of the anesthesia record and operative report attached. Submit the documents in a Special Handling Envelope (HFS 2248). Refer to the "W
tab for a link to Medical Forms Request - Paper/Envelopes page.

received for an encounter visit that has been paid for this date of service and participant. Review the claim and if an error was made, rebill. If no error was made on
t rebill. No payment can be made.

not covered for this provider type/Specialty/Subspecialty.

as been reviewed by the Peer Review Organization/Quality Improvement Organization (PRO/QIO) with one of the following results: Chart was not available or case
resubmit claim or; Partial denial of days—submit a paper claim form to your billing consultant with a copy of the Advisory Notice from the Department's PRO/QIO or;
ubmit a paper claim form to your billing consultant with a copy of the Advisory Notice from the Department's PRO/QIO or; Full denial—do not rebill. Refer to the "We
tab for a link to the Department's PRO/QIO.

received with a participant Date of Birth value that was either missing or not a valid date format. Please verify the recipient's Date of Birth prior to rebilling.

received with a participant Date of Birth value that does not match the Date of Birth on the Department's files. Please verify the participant's Date of Birth prior to reb

submitted with an obsolete third diagnosis code(s). Review and resubmit claim with the appropriate code(s) that are in effect for the date of service being billed. For
to 10-01-2015, refer to the ICD-9 coding manual. For dates of service on or after 10-01-2015, refer to the ICD-10 coding manual.

168 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

submitted with an obsolete fourth diagnosis code(s). Review and resubmit claim with the appropriate code(s) that are in effect for the date of service being billed. Fo
to 10-01-2015, refer to the ICD-9 coding manual. For dates of service on or after 10-01-2015, refer to the ICD-10 coding manual.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

has been temporarily suspended for Department review. Do not rebill. The final status will be reported on a future Remittance Advice.

submitted with an obsolete secondary diagnosis code(s). Review and resubmit claim with the appropriate code(s) that are in effect for the date of service being bille
ior to 10-01-2015, refer to the ICD-9 coding manual. For dates of service on or after 10-01-2015, refer to the ICD-10 coding manual.

submitted with an obsolete principal/primary diagnosis code(s). Review and resubmit claim with the appropriate code(s) that are in effect for the date of service bein
vice prior to 10-01-2015, refer to the ICD-9 coding manual. For dates of service on or after 10-01-2015, refer to the ICD-10 coding manual.

received which is a duplicate of one currently being processed by the Department. The final status of the claim being processed will be reported on a future Remitta
persedes any other error messages that may be received for the service line.

ed by Provider Type 036, Community Mental Health Providers, Other Governmental Payers.

169 of 171
 Claims Processing Error Code Listing
Department of Healthcare and Family Services
Division of Medical Programs
Published: November 2016

Explanation

ant is only allowed one round trip per prior approval per day.

received with no prior approval number reported or the prior approval number that was reported did not match the prior approval number on the participant's prior ap
the date of service billed.

utpatient claims with dates of service on and after 07/01/04. Revenue code 762 must have a corresponding HCPCS code as identified in the Ambulatory Procedures
e Department's Web site. Refer to "Web Site Resources" tab for a link to the APL.

received for a procedure billed with Modifier 50 and the procedure code billed is not appropriate with Modifier 50.

170 of 171
 Error Code Listing Web Site Resources
Published: [insert month/year]
Topic with Hyperlink
Ambulatory Procedures Listing
AVRS - Automated Voice Response System
Contacts at Medicaid Health Plans
Healthcare and Family Services Home Page
Hospital Acquired Conditions (HAC)
IMPACT - Illinois Medicaid Program Advanced Cloud Technology
Instructions for 215 Drug Invoice
MEDI - Medical Electronic Data Interchange
Medical Forms
Medical Forms Request - Paper/Envelopes
Medicaid Reimbursements
Medical Provider Handbooks
NCPDP Companion Guide
Pharmacy Benefits Manager-TPL Resource Code Directory
Pharmaceutical Labelers with Signed Rebate Agreements
Pharmacy Program Home Page
Preferred Drug Listing (PDL)
PRO/QIO - eQHealth
REV - Recipient Eligibility Verfication
SASS - Screening, Assessment and Support Services
Third Party Liability Resource Code Directory
Vaccines for Children Program

Illinois Department of Healthcare and Family Services Division of Medical Programs