ANSI is short form of American National Standards Institute is an insurance subcommittee and CMS-Center for Medicare and Medicaid Services create some reason codes which define the reason when any healthcare claim denied. These reason codes known as ANSI codes and approved by CMS.
When claim is denied due to some reason, this ANSI reason codes define the exact reason of denial for universal explanation of denial reasons and provide uniform action on same type of denial. It will help insurance companies to handle denials swiftly and claims paid on priority.
ANSI Reason Codes and Description
ANSI Codes and Description
1 –Deductible amount.
2 –Coinsurance amount.
3 –Co-payment amount.
4–The procedure code is inconsistent with the modifier used, or modifier is missing.
5 –The procedure code/bill type is inconsistent with the place of service (POS).
6 –The procedure code is inconsistent with the patient’s age.
7 –The procedure code is inconsistent with the patient’s gender.
8 –The procedure code is inconsistent with the provider type/specialty (taxonomy).
9 –The diagnosis (Dx) is inconsistent with the patient’s age.
10 –The diagnosis (Dx) is inconsistent with the patient’s gender.
11 –The diagnosis (Dx) is inconsistent with the procedure.
12 –The diagnosis (Dx) is inconsistent with the provider type.
13 –The date of death (DOD) precedes the date of service.
14 –The date of birth (DOB) follows the date of service.
15 –Payment adjusted because the submitted authorization number is missing/ invalid or does not apply to the billed services or provider.
16 –Claim or service lacks information which is needed for adjudication.
17 –Payment adjusted because requested information was not provided or insufficient/incomplete.
18 –Duplicate Claim or service.
19 –Claim denied because this is a work-related injury or illness and thus the liability of the Worker’s Compensation Carrier.
20 –Claim denied because this injury or illness is covered by the liability carrier.
21 ==Claim denied because this injury or illness is the liability of the no-fault carrier.
22 –Payment adjusted because this care may be covered by another payer per coordination of benefits.
23 –Payment adjusted because charges have been paid by another payer.
24 –Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
25 –Payment denied. Your stop loss deductible has not been met.
26 –Expenses incurred prior to coverage.
27 –Expenses incurred after coverage terminated.
28 –Coverage not in effect at the time the service was provided.
29 –The time limit for filing has expired.
30 –Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
31 –Claim denied as patient cannot be identified as our insured.
32 –Our records indicate that this dependent is not an eligible dependent as defined.
33 –Claim denied. Insured has no dependent coverage.
34 –Claim denied. Insured has no coverage for newborns.
35 –Benefit maximum has been reached.
36 –Balance does not exceed co-payment amount.
37 –Balance does not exceed deductible.
38 –Services not provided or authorized by designated (network) providers.
39 –Services denied at the time authorization/pre-certification was requested.
40 –Charges do not meet qualifications for emergent/urgent care.
41 –Discount agreed to in Preferred Provider contract.
42 –Charges exceed our fee schedule or maximum allowable amount.
43 –Gramm-Rudman reduction.
44 –Prompt-pay discount.
45 –Charges exceed your contracted/legislated fee arrangement.
46 –This (these) service(s) is (are) not covered.
47 –This (these) diagnosis (Dx)(es) is (are) not covered, missing, or are invalid.
48 –This (these) procedure(s) is (are) not covered.
49 –These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
50 –These are non-covered services because this is not deemed a “medical necessity” by the payer.
51 –These are non-covered services because this is a pre-existing condition.
52 –The referring/prescribing provider is not eligible to refer/prescribe/order/perform the service billed.
53 –Services by an immediate relative or a member of the same household are not covered.
54 –Multiple physicians/assistants are not covered in this case.
55 –Claim or service denied because procedure/ treatment is deemed experimental/ investigational by the payer.
56 –Claim or service denied because procedure/ treatment has been deemed “proven to be effective” by the payer.
57 –Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day’s supply.
58 –Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
59 –Charges are reduced based on multiple surgery rules or concurrent anesthesia rules.
60 –Charges for outpatient services with this proximity to inpatient services are not covered.
61 –Charges adjusted as penalty for failure to obtain second surgical opinion.
62 –Payment denied/reduced for absence of, or exceeded, precertification/ authorization.
63 –Correction to a prior claim.
64 –Denial reversed per Medical Review.
65 –Procedure code was incorrect. This payment reflects the correct code.
66 –Blood deductible.
67 –Lifetime reserve days.
68 –DRG weight.
69 –Day outlier amount.
70 –Cost outlier. Adjustment to compensate for additional costs.
71 –Primary payer amount.
72 –Coinsurance day.
73 –Administrative days.
74 –Indirect Medical Education Adjustment.
75 –Direct Medical Education Adjustment.
76 –Disproportionate Share Adjustment.
77 –Covered days.
78 –Non-covered days/Room charge adjustment.
79 –Cost report days.
80 –Outlier days.
81 –Discharges.
82 –PIP days.
83 –Total visits.
84– Capital Adjustment.
85 –Interest amount.
86 –Statutory Adjustment.
87 –Transfer amount.
88 –Adjustment amount represents collection against receivable created in prior overpayment.
89 –Professional fees removed from charges.
90 –Ingredient cost adjustment.
91 –Dispensing fee adjustment.
92 –Claim paid in full.
93 –No claim level adjustments.
94 –Processed in excess of charges.
95 –Benefits adjusted. Plan procedures not followed.
96 –Non-covered charges.
97 –Payment is included in the allowance for another service/procedure.
98 –The hospital must file the Medicare claim for this inpatient non-physician service.
99 –Medicare Secondary Payer Adjustment amount.
100 –Payment made to patient/insured/responsible party.
101–Predetermination. Anticipated payment upon completion of services or claim adjudication.
102 –Major Medical Adjustment.
103 –Provider promotional discount (e.g., Senior citizen discount).
104 –Managed care withholding.
105 –Tax withholding.
106 –Patient payment option/election not in effect.
107 –Claim or service denied because the related or qualifying Claim or service was not paid or identified on the claim.
108 –Payment adjusted because rent/purchase guidelines were not met.
109 –Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
110 –Billing date predates service date.
111 –Not covered unless the provider accepts assignment.
112 –Payment adjusted as not furnished directly to the patient and/or not documented.
113 –Payment denied because service/procedure was provided outside the United States or as a result of war.
114 –Procedure/product not approved by the Food and Drug Administration.
115– Payment adjusted as procedure postponed or cancelled.
116 –Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
117 –Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
118 –Charges reduced for ESRD network support.
119 –Benefit maximum for this time period has been reached.
120 –Patient is covered by a managed care plan.
121 –Indemnification adjustment.
122 –Psychiatric reduction.
123 –Payer refund due to overpayment.
124 –Payer refund amount – not our patient.
125 –Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.
126 –Deductible – Major Medical.
127 –Coinsurance – Major Medical.
128 –Newborn’s services are covered in the mother’s allowance.
129 –Payment denied. Prior processing information appears incorrect.
130 –Claim submission fee.
131 –Claim specific negotiated discount.
132 — Prearranged demonstration project adjustment.
133 –The disposition of this Claim or service is pending further review.
134 –Technical fees removed from charges.
135 –Claim denied. Interim bills cannot be processed.
136 –Claim adjusted. Plan procedures of a prior payer were not followed.
137 –Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
138 –Claim or service denied. Appeal procedures not followed or time limits not met.
139 –Contracted funding agreement. Subscriber is employed by the provider of the services.
140 – -Patient/Insured health identification number and name do not match.
141 –Claim adjustment because the claim spans eligible and ineligible periods of coverage.
142 –Claim adjusted by the monthly Medicaid patient liability amount.
143 –Portion of payment deferred.
144 –Incentive adjustment, e.g., preferred product/service.
145 –Premium payment withholding.
146 –Payment denied because the diagnosis (Dx) was invalid for the date(s) of service reported.
147 –Provider contracted/negotiated rate expired or not on file.
148 –Claim or service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
A0 –Patient refund amount.
A1 –Claim denied charges.
A2 – -Contractual adjustment.
A3 –Medicare Secondary Payer liability met.
A4 –Medicare Claim PPS Capital Day Outlier Amount.
A5 –Medicare Claim PPS Capital Cost Outlier Amount.
A6 –Prior hospitalization or 30 day transfer requirement not met.
A7 –Presumptive Payment Adjustment.
A8 –Claim denied; ungroupable DRG.
B1 –Non-covered visits.
B2 –Covered visits.
B3 –Covered charges.
B4 –Late filing penalty.
B5 –Payment adjusted because coverage/program guidelines were not met or were exceeded.
B6 –This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
B7 –This provider was not certified/eligible to be paid for this procedure/service on this date of service.
B8 –Claim or service not covered/reduced because alternative services were available, and should not have been utilized.
B9 –Services not covered because the patient is enrolled in a Hospice.
B10 –Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
B11 –The Claim or service has been transferred to the proper payer/processor for processing. Claim or service not covered by this payer/processor.
B12 –Services not documented in patient’s medical records.
B13– Previously paid. Payment for this Claim or service may have been provided in a previous payment.
B14 –Payment denied because only one visit or consultation per physician per day is covered.
B15 –Payment adjusted because this service/procedure is not paid separately.
B16 –Payment adjusted because “new patient” qualifications were not met.
B17 –Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.
B18 –Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
B19 –Claim or service adjusted because of the finding of a Review Organization.
B20 –Payment adjusted because procedure/service was partially or fully furnished by another provider.
B21 –The charges were reduced because the service/care was partially furnished by another physician.
B22 –This payment is adjusted based on the diagnosis (Dx).
B23 –Payment denied because this provider has failed an aspect of a proficiency testing program.
D1– Claim or service denied. Level of subluxation is missing or inadequate.
D2 –Claim lacks the name, strength, or dosage of the drug furnished.
D3 –Claim or service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
D4 –Claim or service does not indicate the period of time for which this will be needed.
D5 –Claim or service denied. Claim lacks individual lab codes included in the test.
D6 –Claim or service denied. Claim did not include patient’s medical record for the service.
D7 –Claim or service denied. Claim lacks date of patient’s most recent physician visit.
D8 –Claim or service denied. Claim lacks indicator that “x-ray is available for review”.
D9 –Claim or service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
D10 –Claim or service denied. Completed physician financial relationship form not on file.
D11 –Claim lacks completed pacemaker registration form.
D12 –Claim or service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
D13 –Claim or service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
D14 –Claim lacks indication that plan of treatment is on file.
D15 –Claim lacks indication that service was supervised or evaluated by a physician.
W1 –Workers Compensation State Fee Schedule Adjustment.
ANSI Codes are created by American National Standards Institute (ANSI) and approved by CMS and also they updated these codes time to time. We tried to provide the latest information but if any discrepancy found please let us know via contact us page.