Segment
X12 EDI Release 00306
To specify the outcome of a health care services review
Elements
Code indicating type of action
Codes (168)- 1Add
- 2Change (Update)
- 3Delete
- 4Verify
- 5Send
- 6Receive
- 7Request
- 8In Production Send
- 9Not Capable of Taking Action
- 15Correct and Resubmit Claim
- 23Escalation
- 24On-Hold
- 26Bankruptcy Filed - Review Account
- 27Moved - Follow Up
- 28Change Phone Number
- 29Payment Received - Follow Up
- 30Account Active - Pursue
- 31Return per Client Request
- 32Pursue Legal Action
- 34Pursue Garnishment
- 35New Assignment - Proceed
- 36Repossess Merchandise
- 37Adjust Payment
- 38Change Address
- 39Skiptrace Account
- 40Close Account - Deceased
- 41Update to Inactive
- 42Account Paid in Full - Close Account
- 43Refused to Pay - Review Account
- 44Account Disputed - Review
- 45Do Not Contact - Fair Debt Collection Practices Act (FDCPA)
- 46Forward Account
- 51Complete
- AAdd A Bill of Lading
- CCancelled
- DDelete a Bill of Lading
- EEliminate/Expire
- FFinal
- HMaster-In-Bond (MIB) Arrival
- IReissue
- KIn Production Send and Receive
- LIn Development/Send
- MIn Development/Receive
- NIn Development/Send and Receive
- OIn Test/Send
- PIn Test/Receive
- QIn Test/Send and Receive
- RIn Production Receive
- TStatus Query
- UReject
- VRespond
- WReverse
- ZMutually Defined
- A1Certified in total
- A2Certified - partial
- A3Not Certified
- A4Pended
- A5Upheld
- A6Modified
- AAAward
- ABAbandon
- ACAcknowledge
- ADDecrease in Amount
- AEActivate
- AFAffirm
- AIIncrease in Amount
- ALAllow
- APAppeal
- ASDiscovered
- ATAppoint
- AVCancellation Not Effected
- AWMass Cancellation
- AXPartial Cancellation
- BDBoard
- BIBifurcate
- BOUse Both Date and Meter Criteria
- CBCut
- CECharge
- CFConfirm
- CLClosed
- CNConsolidated
- COCorrect
- CSTransfer of Claim for Security
- CTContact Payer
- CUContinue
- CVConvert
- CXClaim Transferred
- DCDelivered to Another Carrier
- DEDeny
- DFDefer
- DIDismissed with Prejudice
- DJDismissed without Prejudice
- DKDispose
- DLDivert
- DPDelivered to Public Warehouse
- DSDiscarded
- DXDischarged
- ENEnter
- EPEntire Patient Information
- ERExtension Request
- EXExtend
- FIFile
- FOForfeit
- FRPatient Follow-Up Required
- GRGrant
- HRHold Until Released
- IADeactivate
- INInterim
- ISIssue
- ITInitiate
- JOJoin
- JUJudgment
- KARegistration Confirmed
- LCLeft at Consignee
- LQLiquidate
- MEMerge
- NANo Action Required
- NDNo Change
- NPNot Present
- NSDo Not Send
- ODOrder
- ORUse Date or Meter Criteria (whichever occurs first)
- OTOther Unlisted Action
- PBPartial Transfer of Claim
- PFPreliminary Final
- PIProvide Additional Information
- PPPartial Patient Information
- PRPresent
- R1Reopened
- R2Send Record Now
- R3Send Record at End of the Term
- R4Send Record After Degree is Posted
- R5Send Vocational Record Only
- R6Transfer
- R7Assumption
- R8Terminate
- R9Reinstate
- RARemove
- RBResecure
- RCReturned to Carrier Facility
- REReleased
- RFReturned to Shipper's Facility (Other Than Original Shipping Location)
- RGRefer
- RHRecall
- RLReschedule
- RMRemand
- ROReturned to Original Shipping Location
- RRReverse and Remand
- RSReport Status
- RUReturn
- RVRevoke
- RXReplace
- S1Secure
- SASatisfy
- SCScreen
- SESettle
- SLSchedule
- SRServe
- SUSuspend
- SVSever
- SZSeize
- TRTrim
- VAVacate
- W1Reconcile Historical Records
- WDWithdrawn
- WIWinterize
- WQAccept
- WVWaive
Code assigned by issuer to identify reason for rejection
Codes (107)- 10Administrative Cancellation
- 11Invalid Debit Number
- 12Duplicate Sequence Number
- 13Not Valid for Price Protection
- 14Invalid part number
- 15Required application data missing
- 16Unit resale higher than authorized
- 17Negotiated price was not less than book price
- 18Ship date must not be after current date
- 19Ship date cannot be prior to price authorization issue date
- 20Ship date should not be before price authorization date (for rebills)
- 21Price authorization is a rebill type
- 23Price authorization has been deleted
- 24Price authorization used on a sales order
- 25Disposition pending vendor review.
- 26Invalid Customer Number
- 27Invalid Ship Date
- 28Duplicate Invoice Number
- 29Claim Submitted Past Exercise Period
- 30Invalid Meet Competition Cost
- 31Invalid Book Cost
- 32Input Incomplete
- 33Input Errors
- 34No Coverage
- 35Out of Network
- 36Testing not Included
- 37Request Forwarded To and Decision Response Forthcoming From an External Review Organization
- 41Authorization/Access Restrictions
- 42Unable to Respond at Current Time
- 43Invalid/Missing Provider Identification
- 44Invalid/Missing Provider Name
- 45Invalid/Missing Provider Specialty
- 46Invalid/Missing Provider Phone Number
- 47Invalid/Missing Provider State
- 48Invalid/Missing Referring Provider Identification Number
- 49Provider is Not Primary Care Physician
- 50Provider Ineligible for Inquiries
- 51Provider Not on File
- 52Service Dates Not Within Provider Plan Enrollment
- 53Inquired Benefit Inconsistent with Provider Type
- 54Inappropriate Product/Service ID Qualifier
- 55Inappropriate Product/Service ID
- 56Inappropriate Date
- 57Invalid/Missing Date(s) of Service
- 58Invalid/Missing Date-of-Birth
- 59Invalid/Missing Date-of-Death
- 60Date of Birth Follows Date(s) of Service
- 61Date of Death Precedes Date(s) of Service
- 62Date of Service Not Within Allowable Inquiry Period
- 63Date of Service in Future
- 64Invalid/Missing Patient ID
- 65Invalid/Missing Patient Name
- 66Invalid/Missing Patient Gender Code
- 67Patient Not Found
- 68Duplicate Patient ID Number
- 69Inconsistent with Patient's Age
- 70Inconsistent with Patient's Gender
- 71Patient Birth Date Does Not Match That for the Patient on the Database
- 72Invalid/Missing Subscriber/Insured ID
- 73Invalid/Missing Subscriber/Insured Name
- 74Invalid/Missing Subscriber/Insured Gender Code
- 75Subscriber/Insured Not Found
- 76Duplicate Subscriber/Insured ID Number
- 77Subscriber Found, Patient Not Found
- 78Subscriber/Insured Not in Group/Plan Identified
- 79Invalid Participant Identification
- 80No Response received - Transaction Terminated
- 81Invalid or Missing Case Number
- 82Not Medically Necessary
- 83Level of Care Not Appropriate
- 84Certification Not Required for this Service
- 85Certification Responsibility of External Review Organization
- 86Primary Care Service
- 87Exceeds Plan Maximums
- 88Non-covered Service
- 89No Prior Approval
- 90Requested Information Not Received
- 91Duplicate Request
- 92Service Inconsistent with Diagnosis
- 95Patient Not Eligible
- 96Pre-existing Condition
- 97Invalid or Missing Provider Address
- 98Experimental Service or Procedure
- 01Price Authorization Invalid
- 02Price Authorization Expired
- 03Product not on the price authorization
- 04Authorized Quantity Exceeded
- 05Zero Balance
- 06Special Cost Incorrect
- 07Catalog Cost Incorrect
- 08Invalid Ship Location
- 09No Credit Allowed
- E1Requested Record Will Not Be Sent; Cannot Identify the Record
- E2Requested Record Will Not Be Sent; Need Student or Parent Permission
- E3Requested Record Will Not Be Sent
- E4Requested Record Will Not Be Sent; Never Enrolled
- E5Requested Record Will Not Be Sent; No Degree Awarded
- E6Requested Record Will Not Be Sent; No Grades Posted
- E7Requested Record Cannot Be Sent Electronically; Record Resides in Paper Format only which Will Be Sent by Mail
- E8Requires Medical Review
- T1Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4Payer Name or Identifier Missing
- T5Certification Information Missing
- T6Claim does not contain enough information for re-pricing
- ZZMutually Defined
