Reason Code Definitions

This reason code should be used if the claim billed on your case is a duplicate of another claim billed.

• Duplicate Billing of services

• Documentation Does Not Support The Services Billed

• Incorrect Billing of Modifier

This reason code should be used if per our individual Clients’ policies the Service, Benefit, or Supply billed is not covered.

• Paid Greater than Billed

• Services Billed by an Ineligible Provider

• Not a Covered Service, Benefit or Supply

This reason code should be used by the Non-Clinical Investigator. It is used when a specific analytic is hit regarding a claim that is in danger of being paid at a higher amount.

• Upcoding E/M Code

• Paid Greater than Billed

• Unbundled Procedure Code

This reason code should be used if the billed procedure code is a time based code and does not meet the code requirements outlined in the CPT code description.

• Incorrect Records Submitted for Review

• Upcoding of Time Based Code

• Information Requested was Not Received from the Provider

This reason code should be used if the case/claim line will not receive a Clinical Review.

• Closed No Investigation

• Incomplete Medical Records Received

• Incorrect Billing of Modifier

This reason code should be used if the documentation does not support the laboratory code billed.

• Incorrect Billing of Units

• Incorrect Records Submitted for Review

• Incorrect Billing of Laboratory Codes

This reason code should be used if the medical records submitted are incorrect.

• Unbundled E/M Service

• Upcoding E/M Code

• Incorrect Records Submitted for Review

This reason code should be used if the billed procedure code is unbundled from the other procedure codes billed.

• Unbundled Procedure Code

• Upcoding E/M Code

• Upcoding of Procedure Code

This reason code should be used if documentation was not received from the Provider.

• Information Requested was Not Received from the Provider

• No Findings

• Not a Covered Service, Benefit or Supply

This reason code should be used if no medical records were received for the date of service billed or if pieces of medical records are missing.

• Closed No Investigation

• Incorrect Billing of Modifier

• Incomplete Medical Records Received