Logo

Provider Adjustment Reason Codes

X12 External Code Source 967

These codes report payment adjustments that are not related to a specific claim, bill, or service.

Last updated: 5/25/2020

Back Code Lists

Show

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.
Num. Date Requested Description Type Code Status
33 3/26/2018 Temporary Allowance New code C5 On Hold
58 3/26/2018 Return on Equity New code RE On Hold
72 10/16/2018 Void re-issue activity. Included re-issue invoices, debit memos and interest information as a result of federal/state/local mandates. Prerequisite for use of this code requires advance provider outreach. New code On Hold
78 2/28/2019 The amount of the late claim filing penalty, or Medicare late cost report penalty Revision to an existing code 50 On Hold
90 12/10/2019 Prior authorization required. Please submit medical documentation. See Obtaining Covered Services. Revision to an existing code OT4 and OT5 Received
Show

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.

|

Show
01Card interchange fee amount
Start: 10/01/2018
02Advanced or accelerated payment recoupment amount
Start: 03/01/2019
03Claim transmission fee amount
Start: 03/01/2019
04Real-time adjudication resulting in a payment that will follow separately.
Start: 04/11/2019
05Penalty amount withheld due to reports that were not filed
Start: 04/11/2019
06Penalty amount withheld due to reports that were filed incorrectly
Start: 04/11/2019
07Non-Internal Revenue Service third-party withholding amount unrelated to a federal payment levy program
Start: 11/01/2019
08Penalty Withholding for Bankruptcy/Termination
Start: 11/01/2019
50The amount of the late charge, late claim filing penalty, or Medicare late cost report penalty.
Start: 07/01/2018
51Late filing interest penalty assessment amount
Start: 07/01/2018 | Last Modified: 03/01/2019
72Provider refund amount
This adjustment acknowledges a refund received from a provider for previous overpayment.
Start: 07/01/2018 | Last Modified: 03/01/2019
90Early payment allowance amount
Start: 07/01/2018
AHClaim transmission fee amount
This code is used for transmission fees that are not specific to or dependent upon individual claims.
Start: 07/01/2018 | Last Modified: 03/01/2019
AMLoan repayment amount
Start: 07/01/2018 | Last Modified: 03/01/2019
APAdvanced or accelerated payment amount
Start: 07/01/2018 | Last Modified: 04/11/2019
B2Rebate amount
Applies when a provider has remitted an over payment to a health plan in excess of the amount requested by the health plan.
Start: 07/01/2018 | Last Modified: 03/01/2019
B3Recovery amount
This represents the amount received from the provider for an overpayment based on payments from other payers. This code is not used for other provider refund adjustment amounts.
Start: 07/01/2018 | Last Modified: 03/01/2019
BDBad debt amount
Start: 07/01/2018 | Last Modified: 03/01/2019
BNBonus amount
Start: 07/01/2018
CRCapitation interest amount
Start: 07/01/2018
CSAdjustment amount, detailed information is provided separately to explain the adjustment.
Start: 10/01/2018
CTCapitation payment amount
Start: 07/01/2018
E3Withholding amount
Start: 07/01/2018 | Last Modified: 03/01/2019
FBNon-claim related balance forward amount
Start: 07/01/2018 | Last Modified: 03/01/2019
FCAllocation of prepaid funds against which deductions are drawn as services are provided.
Start: 03/01/2019
FRClaim-related balance forward amount
Start: 03/01/2019
HMHemophilia clotting factor add-on payment amount
Start: 03/01/2019
IPIncentive payment amount
Start: 10/01/2018
IRInternal Revenue Service 1099 withholding amount
Start: 03/01/2019
ISLump sum based on an interim rate
Start: 04/11/2019
J1Amount not reimbursed based on a demonstration program or other limitation that prevents issuance of payment.
Start: 03/01/2019
L3Penalty amount
Start: 10/01/2018
L6Interest amount
Start: 03/01/2019
LEInternal Revenue Service non-1099 withholding amount
Start: 03/01/2019
OBAffiliated provider(s) offset amount
Start: 10/01/2018
PIPeriodic Interim Payment (PIP) lump sum amount
Start: 03/01/2019
PLFinal payment or settlement amount
Start: 10/01/2018
RARetroactive adjustment amount
Start: 10/01/2018
SLStudent loan garnishment amount
Start: 10/01/2018 | Last Modified: 03/01/2019
TLThird party liability determination amount
Start: 03/01/2019
WOOverpayment recovery amount
Start: 10/01/2018
WUNon-Internal Revenue Service withholding amount related to a federal payment levy program
Start: 11/01/2019