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Diamond Reason Codes - HIPAA

Updated: 08-18-2011

Adjustment
AD ADAPL Claim Adjusted Due To Provider Appeal
AD ADAUT Claim Adjusted Due To Change In Authorization
AD ADCOB Claim Adjusted For COB
AD ADCOR Claim Adjusted
AD ADERP Claim Adjusted Due To Provider Error
AD ADERR Claim Adjusted Due To Processor Error
AD ADMBR Claim Adjusted Due To Change In Member Eligibility
AD ADWSA AOD Women's Set-aside
AD LMBEN Maximum Benefit for this Service Reached
AD MCDBA Medicaid Billed Amount Correction
AD MCDCR Claim Adjusted Following MH Compliance Review
AD MCDDU Confirmed Medicaid Duplicate Claim (MH Only)
AD MCDHR ODJFS Medicaid Hold and Review
AD MCDIA Medicaid Claim Adjusted (Internal Audit) MH Only
AD MCDMO Medicaid Modifier Correction
AD MCDPR Medicaid Procedure Code Correction
AD MCDPS MCD Place of Service Correction
AD MCDSC Confirmed Not Covered Due to MH Service Content
AD MCDTP Medicaid Third Party Payment Correction
AD MCDPS MCD Place of Service Correction
AD MCDUN Medicaid Units Of Service Correction
AD MCDWC Confirmed Incorrect UCI Billed
AD MCDWD Confirmed Incorrect Date of Service Billed
AD MCDYO Medicaid Claim More Than a Year Old When Received
AD NEGPA Negative Paid Amount
AD NONBA Non-Medicaid Billed Amount Correction
AD NONCR Claim Adjusted Following MH Compliance Review
AD NONDU Confirmed Non-Medicaid Duplicate Claim (MH Only)
AD NONIA Non-Medicaid Claim Adjusted (Internal Audit)
AD NONMO Non-Medicaid Modifier Correction
AD NONON Service Not Included in on-Medicaid Contract
AD NONPR Non-Medicaid Procedure Code Correction
AD NONPS Non-MCD Place of Service Correction
AD NONSC Confirmed Not Covered Due to Service Content
AD NONTP Non-Medicaid Third Party Payment Correction
AD NONUN Non-Medicaid Units Of Service Correction
AD NONWC Confirmed Incorrect UCI Billed
AD NONWD Confirmed Incorrect Date of Service Billed
AD NONYO Non-Medicaid Claim More than a Year Old When Received
AD NPR30 No Provider Response Within 30 Days
AD RWJCF RWJ Adjust CAP to FFS
AD RWJFC RWJ Adjust FFS to Cap
AD UNCPB Uncertified Payback
Allowed
AL DUPOP Potential Dup O/P Claim
AL GRPIN System Generated - Group Ineligible
AL HIPAA HIPAA
AL INFOR Informational Line Item
AL IPCAR Inpatient Carve Out
AL MARP  Cuyahoga County MARP Project
AL MBDEC Member Deceased
AL MBRIN System Generated - Member Ineligible
AL MCDBA Medicaid Billed Amount Correction
AL MCDUN Medicaid Units Of Service Correction
AL NOAUT No Authorization on File
AL NONBA Non-Medicaid Billed Amount Correction
AL NONUN Non-Medicaid Units Of Service Correction
AL PCCNV Amount Allowed Per Conversion Factor
AL PCCRT Amount Allowed Per Case Rate
AL PCFSC Amount Allowed Per Fee Schedule
AL PCMNR Modifier Not Used For This Procedure
AL PCMNV Modifier Not Valid For Procedure Code
AL PCMOD A Modifier Is Required For This Procedure
AL PCPDM Amount Allowed Per Diem Rate
AL PCTBI System Generated - Percent Of Billed
AL PERD1 Per Diem Days 1 Through 3
AL PERD4 Per Diem Days 4 Plus
AL PRE04 Pre FY04
AL PRE2K Closed As Pre-FY-2000 Span
AL PRE99 Service Provider Pre SFY 1999
AL PREGL Pre Go-Live Allowed Reason
AL PRVIN System Generated - Provider Ineligible
AL RSC Allowed Service ODADAS/ODMH/RSC Project
AL SPLUC Special Lucas County Contracting
AL TIERP Tiered Pricing Was Used to Recalculate Allowed Amt.
Check
CK ALIGN Check Alignment
CK CANCL Check Cancel
CoPay
CP 00%SF 0% Sliding Fee
CP 05%SF 5% Sliding Fee Scale
CP 10%SF 10% Sliding Fee Scale
CP 100%F 100% Client Pay
CP 15%SF 15% Sliding Fee Scale
CP 20%SF 20% Sliding Fee Scale
CP 25%SF 25% Sliding Fee Scale
CP 30%SF 30% Sliding Fee Scale
CP 35%SF 35% Sliding Fee Scale
CP 40%SF 40% Sliding Fee Scale
CP 45%SF 45% Sliding Fee Scale
CP 50%SF 50% Sliding Fee Scale
CP 55%SF 55% Sliding Fee Scale
CP 60%SF 60% Sliding Fee Scale
CP 65%SF 65% Sliding Fee Scale
CP 70%SF 70% Sliding Fee Scale
CP 75%SF 75% Sliding Fee Scale
CP 80%SF 80% Sliding Fee Scale
CP 85%SF 85% Sliding Fee Scale
CP 90%SF 90% Sliding Fee Scale
CP 90W FFSE for ODADAS Women's Set-aside Programs
CP 95%SF 95% Sliding Fee Scale
CP CIOOP Member Coinsurance = 0
CP CISTP Deactivated, Duplicate With Coins
CP COINS Member Coinsurance
CP COPAY Client Co-Payment
CP CPPCP Primary Care Co-payment
CP FF10  $10/Month Flat Fee Scale
CP FF100 $100/Month Flat Fee Scale
CP FF125 $125/Month Flat Fee Scale
CP FF15  $15/Month Flat Fee Scale
CP FF150 Summit County Flat Fee Scale
CP FF175 $175/Month Flat Fee Scale
CP FF200 $200/Month Flat Fee Scale
CP FF225 $225/Mo Flat Fee Scale
CP FF25  $25/Month Flat Fee Scale
CP FF250 $250/Month Flat Fee Scale
CP FF5 $5/Month Flat Fee Scale
CP FF50  $50/Month Flat Fee Scale
CP FF75  $75/Mo Flat Fee Scale
CP MAXED System Generated - Oop Limit Has Been Satisfied
CP MCDDF No Copay Applied For Medicaid Member
CP VERIF 100% Co-Pay on Non-MCD/Non-MBR Until Income Verified
Deductible
DD MAXED System Generated - Oop Limit Has Been Satisfied
Hold
HD CLATH Claim Requires Approval
HD CLBIL Please Submit An Itemized Bill From The Provider
HD CLHLD Claim Placed On Hold Due To B-Rule
HD CLMAN Claim Manually Placed On Hold
HD DUPDA Dup Res/Day Services
HD DUPLM Potential Duplicate Claim
HD FRHLD Franklin Claims Hold
HD FRMOD Franklin County Modifiers - Hospital/Penal Sys
HD GRHLD Group On Hold
HD LMARP Limit of One Per Elapsed Year
HD LMBEN Benefit Limit Reached
HD LMDAY Day Servs Limit 1 Per Day
HD LMOUT O/P Limit 24 Hrs/Day
HD LMPHA MH Par Hosp Limit 1/Day Adults
HD LMPHC Par Hosp Limit Two/Day For Children
HD LMRWJ MH RWJ Cuyahoga Waiver
HD MBRIN System Generated - Member Is Ineligible
HD MCDBA Potential Medicaid Billed Amount Correction
HD MCDCR Held Due To Medicaid Compliance Review Results
HD MCDDU Medicaid Potential Duplicate Service
HD MCDHR ODJFS Medicaid Hold and Review
HD MCDMO Potential Medicaid Modifier Correction
HD MCDPR Potential Medicaid Procedure Code Correction
HD MCDTP Potential Medicaid Third Party Payment Correction
HD MCDUN Potential Medicaid Units Of Service Correction
HD MCDWC Incorrect UCI Billed
HD MCDWD Incorrect Date Of Service Billed
HD MEDEF Held For Invalid MEDEF
HD NEGPA Negative Paid Amount
HD NOGLR System Generated - Comp Or G/L Ref Code Is Missing
HD NOMCD Service Not Included In Mcd Contract
HD NONBA Potential Non-Medicaid Billed Amount Correction
HD NONCR Held Due To Non-Medicaid Compliance Review Results
HD NONDU Potential Non-Medicaid Duplicate Service
HD NONMO Potential Non-Medicaid Modifier Correction
HD NONON Service Not Included In Non-Medicaid Contract
HD NONPR Potential Non-Medicaid Procedure Code Correction
HD NONTP Potential Non-Medicaid Third Party Pmt. Correction
HD NONUN Potential Non-Medicaid Units Of Service Correction
HD NONWC Incorrect UCI Billed
HD NONWD Incorrect Date Of Service Billed
HD NOQTY No Units of Service Billed
HD OOCTY Out Of County
HD PCINV Procedure Code Inactive
HD PCREV Procedure Code/Modifier Review
HD PRCLD Non-Medicaid Provider Contract On Hold
HD PRHLD System Generated - Provider On Hold
HD PRINF Additional Information Required From Provider
HD RSC All Non-Medicaid Claims Held Pending RSC Payment
HD UNCPB Uncertified Payback
HD VEHLD Vendor On Hold
Not Covered
NC 24HRS Cost Avoidance of 24 Hours Per Day
NC 30HPW AOD Limitation of 30 Hrs/Wk CM/GC/IC/MS
NC AUTHC System Generated - Authorization Is Closed
NC AUTHD System Generated - Authorization Has Been Denied
NC DUPLY Duplicate Claim
NC DXMIS Not Covered Because Diagnosis Is Missing
NC GRANT Grant Based Non-MCD Funding (100% Withhold)
NC INVPC Invalid Procedure Code/Modifier Combination
NC LMARP Limit Of One Per Elapsed Year
NC LMBEN Maximum Benefit For This Service Reached
NC LMDAY Day Servs Limit 1 Per Day
NC LMDIP AOD DIP Services Limit of One Per Day
NC LMEAT Meals Service Limited to 3 Meals Per Day
NC LMMTH Limits Billing To One Per Elapsed Month (28 Days)
NC LMOUT O/P Limit 24 Hrs/Day
NC LMPHA Par Hosp Limit One/Day For Adults
NC LMPHC Par Hosp Limit Two/Day For Children
NC LMRWJ MH RWJ Cuyahoga Waiver
NC LMTRS Limits Transportation to One Per Elapsed Month
NC MAXED System Generated - Oop Limit Has Been Satisfied
NC MBDEC Member Deceased
NC MCDBA Confirmed Medicaid Billed Amount Correction
NC MCDCR Claim Not Covered Following MH Compliance Review
NC MCDDU Confirmed Medicaid Duplicate Service
NC MCDEL Member Not Medicaid Eligible At Time Of Service
NC MCDHR ODJFS Medicaid Hold and Review
NC MCDIA Medicaid Claim Adjusted (Internal Audit) MH Only
NC MCDMO Confirmed Medicaid Modifier Correction
NC MCDPR Confirmed Medicaid Procedure Code Correction
NC MCDSC Confirmed Not Covered Due To Service Content
NC MCDTP Confirmed Medicaid Third Party Payment Correction
NC MCDUN Confirmed Medicaid Units Of Service Correction
NC MCDWC Confirmed Incorrect UCI Billed
NC MCDWD Confirmed Incorrect Date Of Service Billed
NC MCDYO Medicaid Claim Over 365 Days Old When Received
NC MEDEF Denied For Invalid MEDEF
NC MODFM Missing Or Invalid Modifier Code
NC NCSVC Service/Supply Not Covered
NC NEGPA Negative Paid Amount
NC NOAUT No Authorization on File
NC NONBA Confirmed Non-Medicaid Billed Amount Correction
NC NONCR N-M Adjustment Following MH Compliance Review
NC NONDU Confirmed Non-Medicaid Duplicate Service
NC NONIA Non-Medicaid Claim Adjusted (Internal Audit)
NC NONMO Confirmed Non-Medicaid Modifier Correction
NC NONON Service Not Included in Non-Medicaid Contract
NC NONPR Confirmed Non-Medicaid Procedure Code Correction
NC NONSC Confirmed Not Covered Due To Service Content
NC NONTP Confirmed Non-Medicaid Third Party Pmt. Correction
NC NONUN Confirmed Non-Medicaid Units Of Service Correction
NC NONWC Confirmed Incorrect UCI Billed
NC NONWD Confirmed Incorrect Date Of Service Billed
NC NONYO Non-Medicaid Claim Is Over 365 Days Old When Rcvd.
NC NOQTY No Units of Service Billed
NC NPR30 No Provider Response Within 30 Days
NC OOCTY Out Of County Not Covered
NC PCINV Procedure Code Invalid Or Nonspecific
NC RSC Service Not Covered Under ODADAS/ODMH/RSC Project
NC UNCPB Uncertified Payback
Other Carrier
OC 2 Blue Cross/Blue Shield
OC 3 Other Priv Ins
OC 4 Employer/Union
OC 5 Public Agency
OC 6 Other Carrier
OC 9 Harbor Other Carrier
OC E Benefits Exhausted
OC F No Coverage For Any Family Member
OC L Disputed
OC P No Coverage For This Member
OC R No Response From Ins Co
OC S Not Covered Service
OC X Non-Cooperative Member With Insurance
Place of Service
PL 01 Pharmacy
PL 03 School
PL 04 Homeless Shelter
PL 05 Indian Health SVC Free-Standing Facility
PL 06 Indian Health SVC Provider-Based Facility
PL 07 Tribal 638 Free-Standing Facility
PL 08 Tribal 638 Provider-Based Facility
PL 09 Prison/Correctional Facility
PL 11 Office
PL 12 Home
PL 13 Assisted Living Facility
PL 14 Group  Home Foster Care State Custody
PL 15 Mobile Unit
PL 16 Temporary Lodging
PL 17 Walk-in Retail Health Clinic
PL 20 Urgent Care Facility
PL 21 Inpatient Hospital
PL 22 Outpatient Hospital
PL 23 Emergency Room - Hospital
PL 24 Ambulatory Surgical Center
PL 25 Birthing Center
PL 26 Military Treatment Facility
PL 31 Skilled Nursing Facility
PL 32 Nursing Facility
PL 33 Custodial Care Facility
PL 34 Hospice
PL 41 Ambulance -- Land
PL 42 Ambulance -- Air or Water
PL 49 Independent Clinic
PL 50 Federally Qualified Health Center
PL 51 Inpatient Psychiatric Facility (IMD)
PL 52 Psychiatric Facility Partial Hospitalization
PL 53 Community Mental Health Center
PL 54 Intermediate Care Facility/MR
PL 55 Residential Substance Abuse Treatment Facility
PL 56 Psychiatric Residential Treatment Center
PL 57 Non-Residential Substance Abuse Treatment Facility
PL 60 Mass Immunization Center
PL 61 Comprehensive Inpatient Rehabilitation Facility
PL 62 Comprehensive Outpatient Rehabilitation Facility
PL 65 End Stage Renal Disease Treatment Center
PL 71 Public Health Clinic
PL 72 Rural Health Clinic
PL 81 Independent Laboratory
PL 99 Other Place of Service
Service
SV CPST Comm Psych Sup Therapy
SV PH Partial Hospitalization
Term
TM CLSED Provider Closed
TM EDUP1 Electronic Duplicate Same SSN/D.O.B.
TM EDUP2 Electronic Duplicate - Invalid D.O.B
TM EDUP3 Electronic Duplicate - Invalid SSN
TM ERR01 Invalid Required Field
TM ETERM Member Terminated Electronically
TM FSCHD Fee Schedule
TM HIPAA HIPAA
TM IPUCI Invalid Pseudo UCI Code
TM LBCLR Local Board Contract Limits Reached
TM MBDEC Member Deceased
TM MBINL Member Ineligible
TM MBMOS Member Moved Out of State
TM MBMOV Member Left Service Area/Moved
TM MBPLC Plan Changed Manually By Board
TM MERGR Provider Merged
TM PRAEX Providers AoD Certification Has Expired
TM PRCHG Price Region Changed
TM PRDEX Both AoD And MH Certifications Have Expired
TM PRE2K PROVC Term Reason Of Pre SFY 2000
TM PREGL Pre Go-Live Contract Terminated
TM PRMEX Providers MH Certification Has Expired
TM PRVOL Provider Contract Terminated (Voluntary)
TM PSCHG Primary And/Or Alternate Price Schedule Changed
TM RIDER Rider Change
TM RSC ODADAS/ODMH/RSC Project Over
TM VNDCH Vendor Changed