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Service Review Decision Reason Codes

X12 External Code Source 886

These codes communicate the reason for the health care services review outcome.

Last updated: 11/1/2017

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The list below shows the status of change requests which are in process.

Each request will be in one of the following statuses:

  1. Received
    The request has been submitted but is not yet under review.
  2. Triaged
    Staff has looked at the request to ensure it's a legitimate request (not spam), that it is assigned to the correct CMG, and that all required information is present.
  3. In Process
    The CMG has initiated their decision process.
  4. On Hold
    The CMG has initiated their decision process but cannot complete it at this time.
  5. CMG Approved
    The CMG has considered and approved the request, this does not mean it was approved exactly as submitted, it means maintenance related to the request was approved. Requests in this status will be applied to the next version.
  6. CMG Disapproved
    The CMG has considered and disapproved the request, no maintenance action will occur. Requests in this status are complete/final.
No current requests. This list has been stable since the last update. It will not be updated until there are new requests.
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Use the form below to request maintenance to the Code List. Maintenance includes a request for a new code, a revision to the description of code, or deactivation of a code.

Note
The information submitted on this form may be edited for clarity or accuracy during the X12 triage and consideration processes.

Fields marked with an asterisk are required. Existing Code is required on requests for revision or deactivation of a code.

* Name
* Phone
* Email
* Request Type
Existing Code

* Brief description, published with the Code

Extended description, published with the Code

* Include the business justification for this maintenance request here, including who would benefit and the circumstances that make the request appropriate or necessary.

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01Price Authorization Expired
Start: 01/10/2001
02Price authorization no longer required
Start: 01/10/2001
03Product not on the price authorization
Start: 01/10/2001
04Authorized Quantity Exceeded
Start: 01/10/2001
05Special Cost Incorrect
Start: 01/10/2001
06No Credit Allowed
Start: 01/10/2001
07Administrative Cancellation
Start: 01/10/2001
08Unit resale higher than authorized
Start: 01/10/2001
09Out of Network
Start: 01/10/2001
0ATesting not Included
Start: 01/10/2001
0BRequest Forwarded To and Decision Response Forthcoming From an External Review Organization
Start: 01/10/2001
0CAuthorization/Access Restrictions
Start: 01/10/2001
0DRequires PCP authorization
Start: 01/10/2001
0EProvider is Not Primary Care Physician
Start: 01/10/2001
0FNot Medically Necessary
Start: 01/10/2001
0GLevel of Care Not Appropriate
Start: 01/10/2001
0HCertification Not Required for this Service
Start: 01/10/2001
0JCertification Responsibility of External Review Organization
Start: 01/10/2001
0KPrimary Care Service
Start: 01/10/2001
0LExceeds Plan Maximums
Start: 01/10/2001
0MNon-covered Service
Start: 01/10/2001
0NNo Prior Approval
Start: 01/10/2001
0PRequested Information Not Received
Start: 01/10/2001
0QDuplicate Request
Start: 01/10/2001
0RService Inconsistent with Diagnosis
Start: 01/10/2001
0SPre-existing Condition
Start: 01/10/2001
0TExperimental Service or Procedure
Start: 01/10/2001
0UAdditional Patient Information required
Start: 01/10/2001
0VRequires Medical Review
Start: 01/10/2001
0WDisposition pending review
Start: 01/10/2001
0XService Inconsistent with Provider Type
Start: 01/10/2001
0YService inconsistent with Patient's Age
Start: 01/10/2001
0ZService inconsistent with Patient's Gender
Start: 01/10/2001
10Product/service/procedure delivery pattern (e.g., units, days, visits, weeks, hours, months)
Start: 01/10/2001
11Pricing
Start: 01/10/2001
12Patient is restricted to specific provider
Start: 01/10/2001
13Service authorized for another provider
Start: 01/10/2001
14Plan/contractual guidelines not followed
Start: 01/10/2001
15Plan/contractual geographic restriction
Start: 01/10/2001
16Inappropriate facility type
Start: 01/10/2001
17Time limits not met
Start: 02/01/2002
18Notification received
Start: 06/01/2002
19Cosmetic
Start: 06/01/2002
20Once in a lifetime restriction applies
Start: 02/01/2004
21Transport Request Denied
Start: 06/01/2004
22Ambulance Certification Segment information doesn't correspond to Transport Address Segment
Start: 06/01/2004
23Mileage cannot be computed based on data submitted
Start: 06/01/2004
24Computed mileage is inconsistent with transport information or service units submitted
Start: 06/01/2004
25Services were not considered due to other errors in the request.
Start: 06/06/2010
26Missing Provider Role
Start: 06/05/2011
27Patient is currently in a Health Insurance Exchange premium payment grace period -- first month. Usage: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014 | Last Modified: 07/01/2017
28Patient is currently in a Health Insurance Exchange premium payment grace period -- second month. Usage: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014 | Last Modified: 07/01/2017
29Patient is currently in a Health Insurance Exchange premium payment grace period -- third month. Usage: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014 | Last Modified: 07/01/2017
30Initial Utilization Review In Progress
Start: 11/01/2017
31Escalated Utilization Review in Progress
Start: 11/01/2017