Click on this list of Deny Reason Codes to find out details about the one you're interested in...
A1 DMH Finance Bureau denied the claim
1. The claim had a plan that is not in the providers contract, or
2. There is no more money in the plan on the claim, or
3. MC-EPSDT or Healthy Families plans were on the claim and the claim was not sent to Medi-Cal, or
4. CalWORKs was a plan on the claim and it did go to Medi-Cal.
5. Medi-Cal denied the claim.
If after you research this information you feel the claim was denied in error, contact your DMH Finance Bureau liaison.
Also see HIPAA Deny Reason Code 18. This has been phased out as of August 2005. You may still see this message on claims prior to August 2005.|
B4 Verify LP Delay Reason Code (Inb.837.43)
The delay reason code cannot be 5, 6, 9, 11.
Please Note:
As of June 7, 2006, delay reason code 3 is a valid code.
B7 Verify Service Location Medicare ID (Inb.837.Post.47a)
For directly operated, if Medicare claim, make sure the provider location has a Medicare ID.
If Medi-Cal is the payer and can be billed, make sure the service location Medi-Cal ID is active.
B7 Verify SrvLoc MediCalID (Inb837.Post.52)
For Local Plan Providers (DO & Contract), if Medi-Cal is a payer and can be billed, ensure the service location Medi-Cal ID is active. Medi-Cal can be billed when:
• All the plans in the claim allow Medi-Cal to be billed,
• And the procedure code can be converted to a Medi-Cal procedure code.
B7 Medical billable claims service date (Inb837.Post.58)
Service date over 12 months old and cannot be billed to MediCal.
5 Verify ServLocProv Mode (Inb837.Post.50)
Validate mode of service location consist with proc code service type– Added 6/17/2004 Verify the hrp_provider.mode for the service loc (RU where the service took place). If mode = 10, then we need to make sure that for the proc code listed, hrp_DMHProcedure.Servicetype=O and hrp_DMHProcedure.DayTrmt = Y.
13 Verify Svc Dt - Dt of Death (Inb837.Post.15)
If client Death Date exists in the MHMIS or the IS, the Service Date must prior to or the same.
18 This has been phased out as of August 2005.
You may still see this message on claims prior to August 2005.
DMH Finance Bureau denied the claim.
1. The claim had a plan that is not in the providers contract, or
2. There is no more money in the plan on the claim, or
3. MC-EPSDT or Healthy Families plans were on the claim and the claim was not sent to Medi-Cal, or
4. CalWORKs was a plan on the claim and it did go to Medi-Cal.
5. Medi-Cal denied the claim.
If after you research this information you feel the claim was denied in error, contact your DMH Finance Bureau liaison.
See if these claims had EPSDT or Healthy Families.
run the IS010 report, and look on that report to see if MCal = NO. If it does, these claims have been denied because you have claimed against EPSDT or Healthy Families plans, but you did not send the claim to MediCal first. You can only claim against these plans if you send the claim to MediCal first.
To fix these you should
do a new eligibility check for that service date/month/provider/client.
Make sure MediCal is included.
For EPSDT clients as long as you get a positive response from MediCal, you can go ahead and resubmit making sure that the MediCal checkbox is checked for the claim to go to MediCal on the Admin/claim/payer tab.
For Healthy Family clients, you need to actually check the response which is normally negative from MediCal because you do not get an EVC number for Healthy Family clients. If the response indicates the client does have Healthy Families, make sure the client is enrolled in the healthy family plan (look at the DMH elig response). When you submit the claim out of Admin you need to force the claim to go to Medi-Cal by going to the Payer tab, make sure the Medi-Cal checkbox is checked, enter a "9" in the EVC number field, click continue, go to the Medi-Cal Id field and enter the client CIN #. Click submit.
18 Check for Dup claim (Inb837.Post.4)
The same Claim Id came in 2xs. This is somewhat common for providers who submit through EDI, but should not occur for user who submit claims from Admin.
That being said, this had occurred for those that submit through Admin on certain occasions where claims got suspended and were then resubmitted. If you get this error message call the help desk at 213-351-1335.
22 Verify Medicare Claims (Inb837.Post.46)
For directly operated, make sure Medicare is specified as a payer if all conditions are met.
The service location is Medicare certified.
The service is Medicare reimbursable.
The client has Medicare
The service is not via telephone.
29 Verify Late Claims for Delay R (Inb837.Post.19)
If a claim is filed more than 6 months after the service date, there must be a delay reason code.
31 Verify Subscriber Enrollment (Inb837.Post.10)
Verify the subscriber (client) is enrolled with DMH and is a person. Note that the value in the claim is the client’s DMH ID.
Also may be related to client’s death date.
38 Verify Submitter (Inb837.Post.3)
The submitter last or Organization Name and Submitter Identifier must be a registered provider found on the IS database. The provider must also be active on the date of service.
38 Reject Corrected and Replacement (Inb837.Post.2)
The IS will process only original (1) or voided claims (8).
05/20/2004: Replacement (7) claim are also valid. Only corrected (6) are not accepted.
38 Ensure LP Service Location has Rate for Claim Plans and Procedure Code (Inb837.Post.5.2.E3)
If the CPT code in the claim is not billable under the Plan (i.e. Crisis Intervention is not allowed under AB3632) the claim will be denied, even if there is another Plan in the claim.
45 DMH Financial Adjudication.
The DMH Finance Bureau denied the claim. The Finance Bureau typically denies the claim when the claim has a plan not in the contract or funds for a plan on the contract have run out or Medi-Cal denied the claim. Contact your provider liaison at http://dmh.lacounty.info/hipaa/downloads/ContractList04-05.pdf.
47 Verify Diagnosis Code (Inb837.Post.37)
Ensure the ICD-9 diagnosis code converts to a DSMIV code. There may be a problem with the ICD-9 – DSMIV crosswalk. Call the help desk at 213-351-1335.
52 Ensure LP Rendering Provider has a Taxonomy (Inb837.Post.5.2.E4)
If the claim is from Local Plan provider, ensure the rendering provider’s taxonomy can perform the service. If you receive this error, resubmit -- This edit has been suspended.
52 Verify Rend Provider Medicare ID
(Inb837.Post.42) or (Inb837.Post.47)|For Directly Operated providers the system checks to see if the rendering provider has a Medicare ID in the IS system. If you believe the rendering provide is a Medicare certified provider then call the help desk at 213-351-1335.
96 Validate Client Plans (Inb837.Post.5.2.E1)
For all claims (LP and FFS), ensure the client is actively enrolled and approved for all the plans specified in the claim. To enroll a client in a plan (add a plan) you must do an update enrollment. For instructions on how to do an update enrollment go to http://dmh.lacounty.info/hipaa/do_UsingtheIS.htm
107 Verify Void Claim (Inb837.Post.5)
The voided claim must have a matching original claim. This happens when you try to unlock the voided claim and you try to submit/resubmit. Call the help desk at 213-351-1335.
107 Prior ClaimID for Void/Resubmit (Inb837.Post.5a)
For example if the original (claim A) was denied and then resubmitted as Claim B. To void the claim, Claim B must be voided, not Claim A.
107 For Void, Validate Original or last Resubmitted Status (Inb837.Post.5b)
The last approved claim for a service can be voided. A single service may be submitted multiple times if it is denied multiple times.
107 Prev Resub Status For Resub (Inb837.Post.5c)
Attempted to Re-Submit a transaction that was not in DENIED status.
125 Verify min UOFS data (Inb837.Post.12)
The data was missing when the claim was sent. This is an internal problem and you should be able to resubmit the claim.
125 Client Ineligible for Service|You are claiming against a plan that the client is not enrolled in
You are claiming against a plan that the client's effective date was after the service date of the claim
You are claiming against a plan that the service location does not have in their contract with DMH
You added a plan in the Payer tab when submitting the claim. You must do an Update Enrollment to add a Plan. In order to correctly enroll the client in a plan (add a plan) you must do an Update Enrollment. For instructions on how to do an Update Enrollment go to http://dmh.lacounty.info/hipaa/do_UsingtheIS.htm
125 Verify Service Time (Inb837.Post.45)
Other and Face-to-Face time are zeroes.
125 Verify Staff time limits (Inb837.Post.16)
The staff time has exceeded the limit for the procedure code or minutes not to exceed 8 hours per staff person. See Procedure Codes manual at http://dmh.lacounty.info/hipaa/index.html
125 Plans Need Medi-Cal as a payer (Inb837.Post.54) or Validate Medi-Cal as a payer if plan is EPSDT/HF (Inb837.Post.54)
The claim has MC-EPSDT or Healthy Families as a plan and the claim was not sent to Medi-cal. Check out the training film at http://dmh.lacounty.info/hipaa/co_ISMovies.htm. Select movie called Medi-Cal Eligibility and Denied Claims.
125 Verify Medicare and Insurance (Inb837.Post.17)
For contract providers, Medicare and Insurance claims are submitted before submitting through the IS. Make sure there is an amount paid even if it is $0.00.
For directly operated providers Medicare amount paid should equal $0.00. For Other Insurance, both directly operated providers and contract providers may enter an amount received.
125 Verify Subscriber Info (Inb837.Post.36)
Subscriber (client) address, City, State and Zip and demographic information should be in the claim.
125 Verify Billing and Pay To Prov (Inb837.Post.7)
The billing provider must exist in the IS and be active on the service date of the claim. The help desk needs to look up the provider information (not the rendering provider but the provider legal entity and verify that it is correct. The user may have to submit paperwork to update provider info.
125 Verify Svc Dt - Current Dt (Inb837.Post.28)
Ensure the service date is not more that a year before the current date.
125 Verify Receiver (Inb837.Post.6)
The receiver of all claims must be DMH.
125 Verify Payer (Inb837.Post.11)
Verify the payer referenced on the inbound 837 claim is DMH.
125 Verify FFS 2 Plan (Inb837.Post.30)
If the claim is from FFS 2 provider, ensure only MCF is sent as plan in the other payer loop. Note that a plan does not have to be present in the transaction.
125 Verify Directly Operated Prov (Inb837.Post.8)
Claims from Directly Operate providers must have DMH as the pay to provider and an organization as the billing provider.
125 Verify Birth Dt - Dt of Death (Inb837.Post.23)
Ensure the subscriber’s birth date is not after the date of death.
136 Verify Insurance Type Code (Inb837.Post.49)
REMOVED 12/15/2004
If an Other payer in Medi-Cal or Medicare, ensure the Insurance type code is valid.
• Medical = ‘MC’
• Medicare = ‘MB’
• Insurance = Anything other than MC or MB. Typically is set to ‘CI’.
147 Ensure LP service location (RU) has a rate table (Inb837.Post.5.2.E1)
If the CPT code in the claim is not billable under the Plan (i.e. Crisis Intervention is not allowed under AB3632) the claim will be denied, even if there is another Plan in the claim with the same CPT code that is billable to Medi-Cal (CI is billable under EPSDT).
148 Verify Med-Cal and Medicare ID (Inb837.Post..39)
If Medi-Cal is specified as a payer the Medi-Cal ID must be in the CIN format – 8 digits and a capital letter. Cannot use all 9’s and a letter.
If Medicare is specified as a payer, ensure the clients Medicare ID is in the format a minimum of 9 and max of 12 (such as A12345678XYZA). MHMIS EPI2 screen format.
148 Validate Client Medicare Eligibility (Inb837.Post.46A)
If the client had Medi-Cal and deleted the Medicare ID on the clinical tab the user may receive error message “VALIDATE CLIENT MEDICARE ELGIBILITY” the user received message in error and should resubmit claim. Issue fixed 09/2005.
If Medicare is listed on the Financial Tab, Medicare needs to be included as a payer if the Medi-Cal eligibility check also shows Medicare.
148 Verify Insurance Rendering Prov (Inb837.Post.21)
If a payer is 3rd party insurance and a rendering provider for insurance exists, it must be of type “Commercial Identifier”. In addition there can only be one rendering provider of type commercial identifier.
Validate Medicare and Insurance Paid Amount (Inb837.Post.54)
Ensure Medicare and/or Other Third Party Insurance paid amounts do not exceed the total claim amount.
Validate Data Like bad data in address line (Inb837.Post.61)
Resubmit Claim.
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