HIPAA Adjustment and Remark Code Crosswalk

HIPAA Adjustment and Remark Code Crosswalk

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Oxford Code Description

A 1 A3 An adjustment has been made on this claim and now reflects the correct deductible amount required. The Member's year to date deductible information is noted below.

A 2 A4 An adjustment has been made on this claim and now reflects the correct coinsurance amount required on this claim. The Members year to date deductible is noted below.

A 3 A4 An adjustment has been made on this claim and now reflects the correct coinsurance amount required on this claim. The Members year to date deductible is noted below.

A 3 A87M This claim was paid per the Member's benefit and the indicated Copay is the Member's responsibility. The copay is not part of the member's max out of pocket Amount.

A 3 TERC Please verify member’s benefits for copay. A 4 D13R The Procedure code billed can be classified as a bilateral procedure.

Therefore, if procedure was performed bilaterally, please re-bill with appropriate units and/or modifier. If not performed bilaterally, please submit with appropriate medical documentation to substantiate. Thank you

A 4 D60I The modifier is missing, invalid or incorrect for the procedure billed. Please submit corrected claim. Deactivated code as of 3/15/2008

A 4 DP46 The submitted modifier is not appropriate when reported with the CPT-4 code or HCPCS code for the rendered service in a facility POS.

A 4 T531 DENIED: This is not a valid modifier for this code. A 4 T535 DENIED: According to Medicare, this is not a valid modifier for this code. A 4 TBIL The procedure code billed can be classified as a bilateral procedure.

Therefore, if procedure was performed bilaterally, please re-bill with appropriate units and/or modifier. If not performed bilaterally, please submit with appropriate medical documentation to substantiate. Thank you

A 5 D13P The CPT code does not correspond with the place of service as billed. Please resubmit the correct place or CPT code. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 5 T509 The CPT code does not correspond with the place of service as billed. Please resubmit the correct place or CPT code.

A 5 TCO1 The CPT code does not correspond with the place of service as billed. Please resubmit the correct place or CPT code.

A 6 D7F This is not a covered expense as the member has aged out of the Birth to Three program and is no longer eligible for coverage.

A 6 D93 Member?s age does not meet infertility guidelines based on policy. A 8 T337 These services have been denied since the provider has been deemed to

be ineligible to perform these services under the terms of your plan. A 11 D16B This service has been denied because there is a mismatch between the

diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 D16C This claim has been denied as the diagnosis is not consistent with the disabling condition covered under the extension of benefits provision.


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A 11 D16D This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 T031 This service has been denied because there is a mismatch between the diagnosis and the procedure.









A 11 T301 This service has been denied because there is a mismatch between the diagnosis and procedure.

A 11 T302 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconside

A 11 T321 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


A 11 T352 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration.




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A 11 TAO1 This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TAO2 This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TAO3 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconside

A 11 TAO4 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconside


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A 11 TAU1 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconside

A 11 TAUD This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TBAL This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TBLA This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TCEM This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TCFL This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TCKL This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TCLK This service has been denied because there is a mismatch between the diagnosis and procedure.

A 11 TDV1 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconside

A 11 TDVE This service has been denied because there is a mismatch between the diagnosis and procedure.

A 11 TDX1 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TDX2 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TDX3 This service has been denied because there is a mismatch between the diagnosis and the procedure.


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A 11 TDX4 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconside

A 11 TEC1 This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TECC This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TECM This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TEEM This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TESR This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TFLC This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 THTV This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TLPP This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TNAL This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TNAS This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TNSS This service has been denied because there is a mismatch between the diagnosis and procedure.


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A 11 TOE1 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TOEM This service has been denied because there is a mismatch between the diagnosis and procedure.

A 11 TPG1 This service has been denied because there is a mismatch between the diagnosis and procedure.

A 11 TPG2 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TPLP This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TRES This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TSIN This service has been denied because there is a mismatch between the diagnosis and procedure.

A 11 TSL1 Diagnosis is inconsistent with services performed, please resubmit with appropriate coding.

A 11 TSL2 This service has been denied because there is a mismatch between the diagnosis and the procedure.

A 11 TUDX This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TVHT This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 11 TVRD This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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A 15 D23 Our records reflect that these services were not pre-certified through Oxford's Medical management Department. Oxford requires pre-certification at least 14 days in advance for all elective hospitalizations, in and outpatient surgeries, and certain diagnostic tests (e.g. MRI's). Oxford will only provide coverage for those services authorized at the time pre-certification takes place. Any additional procedures performed or unanticipated specialists visits require separate authorization from Oxford's Medical Management Department before those charges will be covered.

A 15 D24 Our records reflect that these services were not pre-certified through Oxford's Medical Management Department. Oxford requires pre-certification at least 14 days in advance for outpatient surgeries performed in a physician's office and for all outpatient surgical procedures and diagnostic testing performed in a hospital Oxford will only provide coverage for those services authorized at the time pre-certification takes place. Any additional procedures performed, hospitalizations or unanticipated specialists visits require separate authorizations from Oxford's Medical Management Department before those charges will be covered.

A 15 D35 Pre-certification is required after the 15th visit for chiropractic services rendered through 12/31/99. The provider needs to call 1-888-454-0620 to request authorization for the services rendered beyond the 15th visit

A 15 D6 These services have been denied since we have no record of being notified of emergency services are unable to determine the nature of services performed. Emergent care is defined as treatment, which if not immediately received, could result in the physical impairment or death of a member. Additionally, Oxford must be notified within 48 hours of an emergency treatment. If you have further questions please contact Member Services.

A 15 D65B Dental services were not authorized as medical in nature or accidental dental thru Oxford Health Plans.

A 16 A18 Our records indicate a comprehensive visit has taken place within the past 6 months, therefore Oxford has recoded the claim line. Additional documentation is required to substantiate medical necessity for future visits.

A 16 A18B Oxford realizes there are times when additional reimbursement is warranted based on the complexity of the procedure. Oxford will allow additional reimbursement for modifiers -22 and -63 based on clinical review of the medical records/reports. Please submit medical documentation (i.e. office notes, operative reports) to substantiate the services billed.

A 16 A34A Oxford Health Plans does not have a referral on file for this service, however we have made an exception to pay for the service. In the future, you should ensure there is a referral on file prior to services. If there is no referral on file, please contact the referring provider to have them submit an electronic referral to Oxford. Referral status can be checked on Oxford's web site at www.oxfordhealth.com.

A 16 A44 This claim has been paid to the patient because we are not in receipt of Form W-9, request for taxpayer identification number and certification. Please forward a copy via facsimile to (203) 851-2750, Attention: Finance Department

A 16 A60G Info required to substantiate claim


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A 16 D13 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13B The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13D This claim could not be processed as the patient's name is missing or unclear. Please resubmit clearly indicating the patient's name. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13E This claim could not be processed as the patient's Oxford ID# is missing from the claim. Please provide and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13F This claim could not be processed as CPT codes were missing. Please provide the appropriate CPT codes and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13G Thisclaim could not be processed as the date of service(s) is missing. Please resubmit the claim with date of service information. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13H This claim could not be processed as the amount billed is missing from the claim. Please supply a billed amount and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13I This claim could not be processed as the name and address of the provider is missing from the claim. Please provide the name and address of the provider and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13J This claim could not be processed as the Federal Tax ID # (FTIN) for the provider is missing. Please provide the FTIN and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D13K This claim could not be processed as the Federal Tax ID# (FTIN) submitted with this claim is incorrect. Please provide the correct FTIN and resubmit the claim. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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A 16 D13L Oxford Health Plans is unable to process this claim because the servicing provider lacks the state licensing information in their Oxford Health account. In order for Oxford Health Plans to abide by state compliance regulations, your provider must submit a new claim, along with their Behavioral Health Registration Certificate, to the following address: Oxford Health Plans, Provider Operations Dept., 10 Tara Blvd., Nashua, NH 03062, Attention: Provider Operations

A 16 D13U These services require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review the operative report for this surgical procedure and any supporting clinical information showing why an assistant surgeon was required. We will use this information to evaluate whether or not the assistant surgeon services were medically necessary. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45-days, to: Oxford Health Plans, Inc., Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027 (Please note that federal law requires the provider to supply a patient with medical notes if requested.)

A 16 D13V Send entire Medical Records to: Oxford Health Plans, Inc. Attention: Debora Scanlon P.O. Box 7078 Bridgeport Connecticut 06601

A 16 D13Z The services denied require clinical review by the Dental Department. In order for us to reconsider payment, please return this EOB with dental documentation (i.e., treatment record notes/operative report, diagnostic test results, imaging (CT/MRI) reports, comprehensive TMJ evaluation) to substantiate the services provided. Do not submit radiographs (digital or standard film) at this time, if needed, radiographs will be requested at the time of review by the Dental Department. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D16 No diagnosis was provided with your claim. Please obtain a diagnosis from your healthcare provider and resubmit this claim. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D16A Oxford is unable to process this claim since a medical diagnosis was not reported for this service. Oxford will only consider claims submitted with a corresponding medical diagnosis code. Please resubmit this claim with the appropriate medical diagnosis code(s) to Oxford and mark the new submission "corrected bill". Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D20 Oxford has denied this claim due to missing information. Additional information concerning this claim was requested more than 30 days ago and has not been received. Please call Member Services for further clarification.

A 16 D20A Oxford is unable to process this claim due to missing information. Oxford requires that all non-participating lab claims include the referring provider’s NPI or UPIN. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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A 16 D29 We need an itemized bill reflecting services rendered to the patient to complete the processing of this claim. Please re-submit this claim with an itemized bill which includes the date of service, procedure code(s) relating to the services performed, medical diagnosis, and corresponding charges.

A 16 D2I An IFSP from the municipality is needed to determine medical necessity. Mail IFSP to Oxford Health Plans, Early Intervention Program, Attn: Clinical Appeals, P.O. Box 7078, Bridgeport, CT 06601.

A 16 D30 We are unable to process these charges with the bill forwarded with this claim. Oxford requires an itemized bill of services which indicates the provider's name, address and tax identification number, the patient's name and identification number, the date(s) of service, CPT code(s), medical diagnosis and billed charges. Please resubmit your claim with an itemized bill including all pertinent billing information.

A 16 D33 We are unable to process this claim as the assignment of benefit information provided is not consistent on the claim form.

A 16 D34 This claim could not be processed with the bill provider. Please resubmit this claim information on a UB92 form.

A 16 D35A This claim has been denied as office notes are needed for review. A 16 D35B This claim has been denied as there is no care plan on file. A care plan is

needed after the 8th visit. A 16 D35E These services require clinical review. Benefits are only available for

covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review medical documentation from this visit. Medical documentation includes: (1) office notes that detail the members condition and progress, specifically range of motion measurements, strength measurements, functional deficits, and pain level, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the service billed matches the service provided. You should return a copy of this Remittance Advice, along with the medical documentation related to these services, within 45 days, to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 D35F These services require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review medical documentation for each date that the Member received care from you, starting from when the member began care for this episode. Medical documentation includes: (1) office notes, SOAP (subjective, objective, assessment, plan/procedure) notes with exam narratives, or equivalent notes which show the Member's condition and progress, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the level of service billed matches the service provided. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45 days, to: TRIAD Healthcare, Inc., P.O. Box 905, Plainville, CT 06062-0905. (Please note that federal law requires you to supply the Member with medical notes upon the Member's request.) If notes have been sent directly to TRIAD, you do not need to resubmit them in response to this request and will receive a written decision within 30 days from TRIAD's receipt of the notes. If you would like to confirm that


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TRIAD has received the notes, please call TRIAD at 800-409-9081.

A 16 D35H The services have been reimbursed as authorized by CareCore National. Services related to contrast material were not authorized. If you believe the services billed were medically appropriate, you must submit medical notes demonstrating that the level of service billed was medically appropriate. The medical notes along with this EOB should be sent to CareCore National (address) within 45 days of this notification for additional information.

A 16 D42 Our records reflect that another insurance carrier may be the primary insurer for these services. To date, we have not received a response to the Coordination of Benefits (COB) questionnaire recently forwarded to the Member for completion. All outstanding claims will be reviewed upon receipt of the questionaire from the member.

A 16 D60G Please submit the complete medical record (including but not limited to, initial patient intake form, history, physicals, progress notes, consultation letters, lab/radiology/pathology reports). Submit requested information, including claim form, to PO Box 315, Monroe, CT 06468 within 45 days.

A 16 D60M Further investigation of billed service required; please submit supporting documentation to validate coding. Please submit medical records to Mail Route MN002-0265, 12125 Technology Drive, Eden Prarie, MN 55344.

A 16 D60N Further investigation of billed service required; please submit supporting documentation to validate coding. Please submit medical records to PO Box 315 Monroe CT, 06468 Deactivated code as of 3/15/2008

A 16 DE6 Oxford Health Plans is a United Healthcare subsidiary. This claim could not be processed as procedure codes were missing. Please provide the appropriate procedure codes and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 16 DU1 Oxford Health Plans is a United Healthcare subsidiary. Your have not billed correctly according to your agreement. Please resubmit with CPT Codes for the Surgery to: Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-


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A 16 DU2 Oxford Health Plans is a United Healthcare subsidiary. An itemized bill is needed in order to process this claim in accordance with your United Healthcare agreement. Please resubmit with an itemized bill to: Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 16 DU4 Oxford Health Plans is a United Healthcare subsidiary. It has been noted that this is an interim bill. A resubmission of the final bill is required in order to evaluate this claim for any additional payment. Please resubmit this final claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 DU5 Oxford Health Plans is a United Healthcare subsidiary. A physical address of where services where rendered is needed in order to process this claim in accordance with your United Healthcare agreement. Please resubmit with a physical address to: Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 16 DU7 Oxford Health Plans is a United Healthcare subsidiary. You have not billed correctly according to your agreement. Please resubmit with CPT codes for the Lab services provided to: Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 16 T13B The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 T304 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 T326 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.




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A 16 T502 Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062




A 16 T533 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.T533



A 16 T598 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.


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A 16 TADM The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TBCD The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

16 TBD The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TBD3 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.






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A 16 TBD9 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TBDA The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TBDC The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

A 16 TBDX The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

A 16 TBDY The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

A 16 TBDZ The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

A 16 TBEH Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TCHR The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

A 16 TCOB Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which s

A 16 TD13 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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A 16 TDU1 This claim could not be processed as CPT codes were missing. Please provide the appropriate CPT codes and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TDU2 Thisclaim could not be processed as the date of service(s) is missing. Please resubmit the claim with date of service information. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TDU3 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TFM3 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed.

A 16 TFM4 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed.

A 16 TINJ The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TMF3 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 16 TPS5 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

A 16 TPSY Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which s

A 16 TPT2 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

A 16 TPT3 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.


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A 16 TTR1 Our records indicate a comprehensive visit has taken place within the past 6 months, therefore Oxford has recoded the claim line. Additional documentation is required to substantiate medical necessity for future visits.

A 16 TUNL Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062

A 206 D20F We are unable to process this claim at this time due to a mssing or invalid NPI number which has ben mandated by CMS for submission. Please resubmit this claim with the requested information electronically or to corrected/Resubmitted claims, P.O. Box 7027, Bridgeport, CT 06601-7027

A 17 A12 This claim has been adjusted and now reflects the patient's correct date of birth.

A 17 D107 We had previously requested additional information that is necessary to process your claim. The information submitted does not comply with that request; therefore, your claim has been denied. Participating provider may not balance bill the member for this service.

A 17 D13A CPT code billed is not substantiated by the medical documentation submitted.

A 17 D17 This claims has been denied since we have not receive documentation of this Member's student status for this date of service. Oxford required documentation of full time dependent student status from the Registrar's office of an accredited educational institution at the beginning of the Fall and Spring semesters. Please forward a letter from he Registrar's office indicating full-time student status with this Explanation of Benefits to the Issue Resolutions Department for reconsideration.

A 17 D1M This claim has been denied because 50 signatures were not obtained as required according to the benefit

A 17 D20E This claim was denied due to missing enrollment information which has been requested from the member or the member’s employer and was not received prior to processing of this claim.

A 17 D38C The operative report and other medical documentation previously requested have not been received. As set forth in the Member’s health benefits plan, this information was required to be submitted within 45-days of the notice. We advised you of this timeframe on the prior Remittance Advice for this service and the Member was advised on his/her Explanation of Benefits. Since the requested information was not received, the claim is denied because without the information, medical necessity of the services cannot be established. A separate letter was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180-days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business Member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60-days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance


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Advice.

A 17 D60A Services billed were unable to be substantiated. For reconsideration of this claim, please submit requested records to Oxford Health Plans, P.O. Box 315 Monroe, CT 06468 within 5 business days.

A 17 D60E Oxford has requested information from member/provider in order to consider this claim for payment. That information has not been received at this time. Please submit requested records to Oxford Plans, PO Box 315, Monroe, CT 06468 with in 45 days.

A 17 D60L Charges cannot be considered because services billed are not documented as performed.

A 18 A14 This code, when submitted twice, justifies the replacement shown. A 18 D4 This claim has been denied as it represents a duplicate submission of a

claim previously processed by Oxford. Please check your records for this statement.

A 18 D4A Duplicate Claim. Original being reviewed with consideration of additional information received.

A 18 D4B This claim has been denied as it represents a duplicate submission of a claim previously processed by Oxford. Please check your records for this statement.

A 18 D4F This is a duplicate claims submission. Additional information concerning this claim was requested on a previous claim and has not been received. Please forward the information requested, office notes, SOAP notes with exam narratives, and any results of x-rays or other imaging studies directly to Triad at: Triad Health Care, Inc., P.O. Box 905, Plainville, CT 06062. (Please note that federal law requires you to supply the Member with medical notes upon the Member?s request.) You have 45 days from the date of receipt of the initial EOB to submit this information. Notes not received in the initial time frame must be submitted through the appeals process outlined in the denial notice sent by TRIAD, on behalf of Oxford.

A 18 D64 This claim has been denied since our records reflect that this claim was processed by your prior insurance carrier through Liberty Brokerage. Please contact your prior carrier directly with any questions you may have with this claim.

A 18 T100 This claim has been denied as it represents a duplicate submission of a claim previously processed by Oxford. Please check your records for this statement.


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A 18 T101 This claim has been denied as it represents a duplicate submission of a claim previously processed by Oxford. Please check your records for this state ment.

A 18 T101 This claim has been denied as it represents a duplicate submission of a claim previously processed by Oxford. Please check your records for this state ment.
















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A 18 T316 This code cannot be accepted twice. A 18 T888 This claim has been denied as it represents a duplicate submission of a

claim previously processed by Oxford. Please check your records for this statement.















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A 19 D25 Our records reflect that these expenses are covered under Workers Compensation Insurance. Please have the Member check with their employer for assistance in administering this claim. Secondary benefits for workers compensation are not available under this plan.

A 20 D26 Our records reflect that a motor vehicle insurance carrier is the primary insurer for these services. Please submit these charges to the primary carrier for processing. Once a determination has been reached, please submit an itemized bill of services rendered along with the primary insurer's explanation of benefits (EOB) to: Oxford Health Plans, Attn: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, CT 06601-7027.

A 21 D26 Our records reflect that a motor vehicle insurance carrier is the primary insurer for these services. Please submit these charges to the primary carrier for processing. Once a determination has been reached, please submit an itemized bill of services rendered along with the primary insurer's explanation of benefits (EOB) to: Oxford Health Plans, Attn: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, CT 06601-7027.

A 22 A41 Oxford's payment on this service represents payment as the secondary carrier. The automobile insurance carrier's payment has been reflected. Participating Providers may not balance bill Members for Covered Services in excess of the applicable co-pay, co-insurance, or deductible.

A 22 A41A This service was covered under the member's Motor Vehicle insurance and has been adjusted based on a refund received.

A 22 A41B This service was covered under Workser's Compensation insurance and has been adjusted based on a refund received.

A 22 A48 Based on the submitted diagnosis, we require additional information to determine the nature of the injury incurred. Please contact Oxford's Coordination of Benefits (COB) Department to assist us in completing the processing of this claim.

A 22 A90Y Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Medicare’s allowed amount. The claim was repriced.

A 22 A90Z Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents the primary carrier's allowed amount. The claim was repriced.

A 22 A91 This claim is part of a motor vehicle accident. The amount shown reflects monies collected by Healthcare Recoveries Inc. on behalf of Oxford Health Plans.

A 22 A92 This claim is part of a workmen's compensation case. The adjusted amount reflects monies collected by Healthcare Recoveries Inc. on behalf of Oxford Health Plans.

A 22 A93 This claim is part of a third party liability case. The amount shown reflects monies collected by Healthcare Recoveries Inc. on behalf of Oxford Health Plans.


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A 22 A95A This service was covered under the member's Motor Vehicle insurance and has been adjusted based on a refund received.

A 22 A95B This service was covered under Worker's Compensation insurance and has been adjusted based on a refund received.

A 22 A95C This service was covered under the member's primary carrier and has been adjusted based on a refund received.

A 22 A95D This service was covered by a third party and has been adjusted based on a refund received.

A 22 A95M This service was covered by the member's primary carrier (Medicare) and has been adjusted based on a refund received.

A 22 D42 Our records reflect that another insurance carrier may be the primary insurer for these services. To date, we have not received a response to the Coordination of Benefits (COB) questionnaire recently forwarded to the Member for completion. All outstanding claims will be reviewed upon receipt of the questionaire from the member.

A 22 D51 Veteran Administration Medical Center (VAMC) services are covered under the Veteran's benefit policy. Services from VAMC's were denied for this reason. Please forward claim to the VAMC for processing purposes.

A 22 D52 This service is covered under the Member's Federal Medicare card and is considered exempt from coverage by SecureHorizons®/Oxford plans. This claims should be filed with Federal Medicare.

A 22 D9 Our records reflect that another insurance carrier is the primary insurer for this service. Please submit these charges to the primary carrier for processing. Once a settlement has been reached, please submit an itemized bill of services rendered along with the primary insurer's explanation of benefits (EOB) to: Oxford Health Plans, Attn: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, CT 06601-7027.

A 22 D9X This service has been adjusted based on a refund received. Our records reflect that another carrier is the primary insurer for this service. Please submit these charges to the primary carrier for processing. Once a settlement has been reached, please submit an itemized bill of services rendered along with the primary insurer's explanation of benefits (EOB) to: Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 22 D9Z This service has been adjusted based on a refund received. Our records reflect that another carrier is the primary insurer for this service. Please submit these charges to the primary carrier for processing. Once a settlement has been reached, please submit an itemized bill of services rendered along with the primary insurer's explanation of benefits (EOB) to: Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 23 A104 Oxford's payment on this service represents payment as the secondary carrier which exceeds the normal benefit This payment was adjusted and is being reimbursed from the member's benefit bank

A 23 A106 Payment is reduced because the reimbursement as secondary payor shall not exceed the primary payor's level of reimbursement for this benefit.

A 23 A11 Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Oxford's allowed amount. Participating Providers may not balance bill Members for Covered Services in excess of the applicable co-pay, co-insurance, or deductible.


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A 23 A11Z Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Oxford's allowed amount.

A 23 A39 Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Medicare's allowed amount. Participating Providers may not balance bill Members for Covered Services in excess of the applicable co-pay, co-insurance, or deductible.

A 23 A39Z Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents the primary carrier's allowed amount.

A 23 A40 This claim has been adjusted to reflect Oxford's payment as the Member's primary insurance carrier.

A 23 A5X Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents the billed amount. Participating Providers may not balance bill Members for Covered Services in excess of the applicable co-pay, co-insurance, or deductible.

A 23 A5Y Payment is reduced because the reimbursement as secondary payor shall not exceed the primary payor's level of reimbursement for this benefit.

A 23 A5Z Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents the billed amount.

A 23 A9 This claim has been paid at the HMO per diem rate for ambulatory surgical facility charges. Oxford payment should be considered payment in full. The Member is not responsible for any additional payment, beyond the applicable coinsurance/deductible.

A 23 A90V Oxford's payment on this service represents payment as the secondary carrier. Payment is adjusted because the reimbursement as secondary payor shall not exceed the primary payor's level of reimbursement for this benefit. The claim was repriced.

A 23 A90X Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Oxford’s repriced amount.

A 23 D11X Oxford's payment on this service represents payment as the secondary carrier. This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive. Participating Providers may not balance bill Members for Covered Services in excess of the applicable co-pay, co-insurance, or deductible.

A 23 D14X Oxford's payment on this service represents payment as the secondary carrier. This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive. Participating Providers may not balance bill Members for Covered Services in excess of the applicable co-pay, co-insurance, or deductible.

A 23 D15 Our records reflect that the explanation of benefits provided from the primary carrier is incomplete. Please refer to the additional comments provided below for an explanation of the missing information. Please submit a copy of this statement along with the missing information to: Oxford Health Plans, Attn: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, C 06601-7027. Please contact Oxford's Customer Service department for any further assistance.


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A 23 D63 This Encounter Transaction Was Processed And Denied By The Site Delegated By Oxford To Process Certain Claim Transactions. The Specific Reason For The Denial Can Be Obtained By Contacting The Site Directly.

A 24 A21A Service included in OSM global case rate. Payment wil be rendered in the scheduled PIP payment as described in your case rate agreement.

A 24 A43 Oxford Health Plans participates with USA Managed Care Organization and has paid the claim according to the negotiated rates. Therefore, Oxford's payment is considered payment in full and the Member is not responsible for any additional payment, beyond the applicable coinsurance/deductible.

A 24 A49 Oxford has not issued any payment for this claim since the services performed are covered under the monthly capitated payment issued to your office for SecureHorizons(R)/Oxford Members. The Member is not responsible for any additional payment, beyond applicable costshares.

A 24 A58 These services are not eligible for reimbursement since they are considered to be covered under the Pre-Paid Partnership arrangement.

A 24 A59 This service was provided as a courtesy by Nyack Hospital. A 24 A5E Adjusting OrthoNet line A 24 A90A Payment has been made in accordance with an agreement with United

Healthcare or United Behavioral Health. The Member is not responsible for any payment beyond the applicable copayment, coinsurance or deductible requirements noted.

A 24 A90B Payment has been made in accordance with an agreement with PHCS. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90D Payment has been made in accordance with an agreement with United Healthcare or United Behavioral Health. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90E PayPayment has been made in accordance with an agreement with LaborCare. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90F Payment has been made in accordance with an agreement with Upper Peninsula Health Plan. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90G Payment has been made in accordance with an agreement with Center Care. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90H Payment has been made in accordance with an agreement with Care Trust Networks. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90I Payment has been made in accordance with an agreement with Medcost Preferred. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90J Payment has been made in accordance with an agreement with Private Health Systems. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90K Payment has been made in accordance with an agreement with Medical Data Exchange. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.


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A 24 A90L Payment has been made in accordance with an agreement with Idaho Physicians Network. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90M Payment has been made in accordance with an agreement with Medical Network. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90N Payment has been made in accordance with an agreement with Southwest Michigan Health Network. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90O Payment has been made in accordance with an agreement with Sparrow Physicians Health Network. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90P Payment has been made in accordance with an agreement with Physicians Choice Network. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90Q Payment has been made in accordance with an agreement with Northern Mississippi Health Link. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 A90S Payment has been made in accordance with an agreement with SelectNet Plus. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.

A 24 D28 The services indicated above are not eligible for reimbursement due to a contractual arrangement this provider has with Oxford. They have been prepaid for these services by Oxford. Under this prepaid arrangement Oxfords monthly per member payment is considered payment in full for all lab services.

A 24 D28C The services indicated above are not eligible for reimbursement at this time due to a contractual arrangement you have with United. You will receive payment on your contractual payment schedule for these services. Under this arrangement these services are considered paid in full and the member may not be balanced billed.

A 24 D32 The services indicated above are not eligible for reimbursement on a fee for service basis. Payment for all services rendered to this Member has been prepaid to you under your capitated arrangement with Oxford. Under the capitated agreement, the Member may not be billed directly.

A 24 D44 These services are not eligible for reimbursement since they are reimbursed through the monthly capitated funding arrangement. These services cannot be billed directly to the Member. Please contact Member Services at 800 879-2399 if you have additional questions.

A 24 D57 These services are covered under Medicaid capitation payment. A 24 D58 These services are not eligible for reimbursement since they are

considered to be covered under the Pre-Paid Partnership arrangement. A 24 D83A Member is a part of the Englewood Hospital and Medical Center group

health plan. This benefit is self-funded by Englewood Hospital therefore Oxford Health Plans is not responsible for payment. Please do not bill Oxford.


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A 24 D83B Member is enrolled in the Lenox Hill Hospital and Medical Center group health plan. This benefit is self-funded by Lenox Hill Hospital and all claims for eligible members are processed by Lenox Hill Hospital. Therefore Oxford Health Plans is not responsib

A 24 D83C Member is a part of the Long Island College Hospital and Medical Center group health plan. This benefit is self-funded by LI College Hospital therefore Oxford Health Plans is not responsible for payment. Please do not bill Oxford.

A 24 D83D Member is enrolled in the Robert Wood Johnson and Medical Center group health plan. This benefit is self-funded by Robert Wood Johnson and all claims for eligible members are processed by Robert Wood. Therefore Oxford Health Plans is not responsible for p

A 24 SF1 SELF FUNDED GROUP OVERRIDE A 24 TENG Member is a part of the Englewood Hospital and Medical Center group

health plan. This benefit is self-funded by Englewood Hospital therefore Oxford Health Plans is not responsible for payment. Please do not bill Oxford.

A 24 TLIH Member is a part of the Long Island College Hospital and Medical Center group health plan. This benefit is self-funded by LI College Hospital therefore Oxford Health Plans is not responsible for payment. Please do not bill Oxford.

A 24 TLNH Member is enrolled in the Lenox Hill Hospital and Medical Center group health plan. This benefit is self-funded by Lenox Hill Hospital and all claims for eligible members are processed by Lenox Hill Hospital. Therefore Oxford Health Plans is not responsible for payment or claims processing. Please do not bill Oxford.

A 24 TRWJ Member is enrolled in the Robert Wood Johnson and Medical Center group health plan. This benefit is self-funded by Robert Wood Johnson and all claims for eligible members are processed by Robert Wood. Therefore Oxford Health Plans is not responsible for payment or claims processing. Please do not bill Oxford.

A 26 D3 These services have been denied since the Member was not covered by Oxford on the date services were performed. Please check your records to see if another policy was in effect for this date of services.

A 26 D3A These services were performed prior to the Member's effective date of coverage with Oxford; therefore the claims have been denied. If another policy was in effect on the date services were performed, this claim should be submitted to that carrier.

A 27 D3 These services have been denied since the Member was not covered by Oxford on the date services were performed. Please check your records to see if another policy was in effect for this date of services.

A 27 D3B These services were performed after the Member's coverage with Oxford terminated; therefore the claims have been denied. If another policy was in effect on the date services were performed, this claim should be submitted to the new carrier.

A 29 D99 Oxford's certificate of coverage required that claims be submitted within 90 days of the date of service, although bills are often accepted up to 180 days from the date services were performed. This claim has been denied since it was received after the 180 day filing deadline.

A 29 D99 COB filing deadline has passed


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A 29 TFDB Oxford's certificate of coverage requires that claims be submitted within 90 days of the date of service, although bills are often accepted up to 180 days from the date services were performed. This claim has been denied since it was received after the 180 day filing deadline.

A 29 T416 Claims must be submitted within 90 days of the date of service, although bills are often accepted up to 180 days from the date services were performed. This claim has been denied since it was received after the 180 day filing deadline. Participating providers may not balance bill the member for this service.

A 31 D31 We are unable to process these charges with the bill forwarded with this claim. Oxford requires an itemized bill for services which indicates the provider's name, address, tax identification number, patient's name, patient's Oxford number, date(s) of service, CPT code(s), medical diagnosis and billed charges. Please resubmit your claim with an itemized bill including all of the above information. If this claim was submitted to Oxford in error, please send to the correct insurance carrier.

A 32 D18 Oxford cannot process this claim since the patient is not a covered dependent under the Subscriber's policy.

A 35 A98 Beginning at the Member's 21st outpatient session, the Member's Inpatient Benefit will be exchanged to cover his/her Outpatient sessions at a rate of 1 inpatient session for 2 Outpatient sessions. If the Member does not wish to use this exchange, any visit after the 20th will be denied. If you have any questions, please call the Behavioral Health Department at 800-201-6991

A 35 D7 These services have been denied since they exceed the maximum benefit provided under your plan. Please refer to your certificate of coverage or contact member Services if you have any further questions.

A 35 D7A Short term rehabilitation which includes physical therapy, speech therapy, occupational therapy and cardiac rehabilitation is covered for a 60 consecutive day period beginning with the first date of treatment. This service was performed after the 60 day benefit period had expired and therefore the claim has been denied

A 35 D7C This claim has been denied since the maximum covered benefit for chiropractic treatment has been exceeded for the current plan year.

A 35 D7D This claim has been denied since the maximum covered benefit for mental health services has been exceeded for this current calendar year.

A 35 TCTE These services have been denied since they exceed the maximum benefit provided under your plan. Please refer to your certificate of coverage or contact member Services if you have any further questions.

A 35 TNJE These services have been denied since they exceed the maximum benefit provided under your plan. Please refer to your certificate of coverage or contact member Services if you have any further questions.

A 38 A8F We have added a claim line to reimburse for a chiropractic service approved after review of clinical notes by a chiropractic clinical reviewer. This code will be reimbursed in lieu of a different procedure code which was billed.

A 38 D1X COB Not Covered A 38 D2 These services were formally denied because they were not authorized in

advance A 38 D21A Agency Not Medicare Certified


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A 38 D21C Payment for services prohibited by Medicare Law. Balance billing is also prohibited.

A 38 D22 Oxford has denied this claim because we have no record of receiving an Electronic Referral from the Member's Primary Care Physician, OB/GYN or Select Specialist. The Referring Provider must submit an electronic referral for specialty services in advance and include the number of visits and the Oxford Participating Specialist ID. The Referring Provider's office can obtain a hard copy confirmation of the electronic referral upon submission and should offer a copy of that confirmation to the member. Consulting Specialists should confirm with Oxford that a referral exists in Oxford's system prior to rendering services to the member.

A 38 D2C Authorized radiology code was not billed. Please resubmit with appropiate authorized code.

A 38 D2D These services were formally denied because they were not authorized in advance with Triad.

A 38 D2F1 This service was not authorized in advance, as it had been reviewed prior to services being rendered and was denied. A separate letter was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180 days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60 days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance Advice.

A 38 D2R These services were denied because they were not authorized in advance A 38 D38H This service was denied because a request was made for an in-network

exception to see a non participating provider which was denied due to a participating provider being available and accessible to render services. A separate letter was sent explaining the basis for the denial. If you would like to appeal the Medical Director’s determination, you must follow the appeal rights provided in the separate determination letter and submit an appeal within 180-days from receipt of that letter. If you have any other questions or appeals concerning the processing of this claim, please follow the claim review process shown on the last page of this EOB.

A 38 D41 These services have been denied since they were not authorized in advance by the Member's Primary Care Physician. All specialty services including diagnostic laboratory testing, radiological testing and specialist consultations must be authorized in advance by the Member's Primary Care Physician to be eligible for coverage under SecureHorizons(R)/Oxford plans.

A 38 D41R These services have been denied since they were not authorized in advance by the Member's Primary Care Physician. All specialty services including diagnostic laboratory testing, radiological testing and specialist consultations must be authorized in advance by the Member's Primary Care Physician to be eligible for coverage under SecureHorizons(R)/Oxford plans.

A 38 T514 These services were formally denied because they were not authorized in advance.


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A 38 T515 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 38 T552 These services were formally denied because they were not authorized in advance

A 38 T628 These services were formally denied because they were not authorized in advance

A 38 TPT1 These services were formally denied because they were not authorized in advance

A 39 D23A This claim has been denied as the authorization on file has not been approved by our Medical Management department.

A 40 D6B Oxford provides worldwide coverage for true medical emergencies less the designated Member copayment. An emergency is defined as a sudden onset of symptoms that are life threatening; like chest pain, severe abdominal pain, difficulty in breathing, or hemorrahging. Based on the submitted diagnosis and services rendered, it does not appear that these services meet this definition; therefore the associated claims have been denied. Anyrequest to reconsider this claim must include supporting medical evidence that the services rendered meet Oxford's definition of emergent care as defined in the certificate of coverage. If you have further questions, contact Member Services.

A 45 A87A Alternative Medicine Office Notes Provided For Payment Of This Claim. A 45 A88 With the assistance of Concentra Preferred Systems, this claim has been

processed according to a signed savings negotiation with the provider. A 45 A88A This claim has been processed according to the usual and customary rate

as determined by Concentra Preferred Systems. A 45 A88B This claim has been processed in accordance with your concurrent

agreement with Concentra Preferred Systems, Inc. on behalf of Oxford Health Plans. If you have questions on this agreement, please contact CPS at 800-700-0891.

A 45 A89 With the assistance of OmniClaim, the claim has been processed according to a signed fee agreement negotiated with the provider

A 45 A90 This service has been paid according to the United HealthCare rate agreement. The member is not responsible for any payment for covered services beyond the applicable copayment, coinsurance or deductible requirements.

A 45 A90C This service has been processed according to a fee agreement with the provider. You are not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted in your health benefits plan documentation.

A 45 A95O Outside Vendor requests offset. A 45 A96 Payment has been made in accordance with an agreement with United

Healthcare transitional care rate. The Member is not responsible for any payment beyond the applicable copayment, coinsurance or deductible requirements noted.

A 45 A97 This claim has been paid according to Oxford's reimbursement for Nurse Practitioner's and Physician's Assistants which is 65% of the maximum allowable amount.


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A 45 A97A This claim was paid in accordance to Oxford's reimbursement for Nurse Practitioners and Physician's Assistants performing as assistants to the surgeon which are paid at 13% of the primary surgeon's maximum allowable amount.

A 45 AURN Payment has been made according to your United Resource Network agreement. Under this agreement you may not balance bill the Member for any amount for covered services above the Members applicable copayment, coinsurance or deductible as reflected on this statement.

A 45 D106 Payment is denied because the reimbursement as secondary payor shall not exceed the primary payor?s level of reimbursement for this benefit.

A 45 D11F Per the contract with Matrix Medical Network, Matrix physicians are allowed to bill for one skilled nursing facility visit per day. This visit has been denied as exceeding the contract allowed amount.

A 45 D14C Part of Global Pharmacy Previously Paid to Outside Hospital Facility A 45 D19I Per the contract with Matrix Medical Network, Matrix physicians are

reimbursed for specific contracted services. This service is not covered under the Matrix Medical Network contract.

A 45 D37 PROVIDERS CONTRACT MAXIMUM HAS BEEN REACHED A 45 D53 This service is covered under the member's regular Medicaid card and is

considered exempt from Oxford's Healthy Start coverage and/or policy. Certain services and/or items are covered under the member's regular Medicaid card as this claim represents. Other services are covered under the member's Healthy Start policy. Please forward claim directly to Medicaid and/or member for processing purposes.

A 45 D5E Adjusting OrthoNet claim line. A 45 D5F Adjusting Triad claim line. A 45 D60K Your plan covers the actual cost of reasonable charges for covered

services. The provider waives copay, coinsurance and/or deductible amounts. We have deducted these from the charged amount to determine the actual cost of the services. Please submit proof of payment for copay, coinsurance and/or deductible.

A 45 D94 Billed quantity exceeds maximum number of services allowed A 45 D95O Outside Vendor requests offset. A 45 DE7 Oxford Health Plans is a United Healthcare subsidiary. An itemized invoice

is needed in order to process this service in accordance with your United Healthcare agreement. Please resubmit with an itemized invoice to: Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 45 NE1 CORRECTED CLAIM; ADDITIONAL INFORMATION RECEIVED A 45 NE2 PROVIDER DOES NOT ACCEPT OXFORD RATES; PAID IN FULL. A 45 NE3 ADMINISTRATIVE EXCEPTION A 45 NE5 RECEIVED EOB FROM PRIMARY CARRIER A 45 NE6 CORRECTED CLAIM; CHANGE IN POLICY A 45 NE7 CORRECTED CLAIM TO APPLY RETROACTIVE CONTRACT CHANGE A 45 NE8 CORRECTED CLAIM; RETROACTIVE CHANGE IN MEMBER'S ENROLLMENT

STATUS A 45 R25 Site of Service Differential applied. The allowable amount for this service

has been reduced by 25%.


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A 45 T317 This adjustment code has been applied to indicate that multiple surgical procedures were performed during the same operating session. This claim has been reimbursed in accordance with Oxford's Multiple Surgery policy, which is based upon generally accepted insurance industry standards for reimbursement of multiple surgical procedures. Under this policy, the primary procedure is reimbursed at 100% of the fee schedule (minus any applicable member cost-share). All subsequent procedures are reimbursed at 50% of the fee schedule. The primary surgery has been determined using the Medicare methodology of relying on the Relative Value Units (RVU). Participating providers may not balance bill the member for this service.

A 45 T318 This claim has been adjusted in accordance with generally accepted insurance industry standards for claims billed with multiple surgical procedures. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amountis allowed for any subsequent procedure.

A 45 T477 The payment reflected on this claim was issued at the contracted rate Oxford has negotiated with your facility. The Member is not responsible for any additional payment, beyond the applicable coinsurance/deductible.

A 45 T479 The payment reflected on this claim was issued at the contracted rate Oxford has negotiated with your facility. Based on our agreement, the member should not be balance billed for any amount in excess of the applicable copay, deductible or coinsurance.

A 45 TMAX Billed quantity exceeds maximum number of services allowed. A 45 TMF1 Billed quantity exceeds maximum number of services allowed A 45 TMF2 Billed quantity exceeds maximum number of services allowed A 45 TMF4 Billed quantity exceeds maximum number of services allowed A 45 TURN Payment has been made according to your United Resource Network

agreement. Under this agreement you may not balance bill the Member for any amount for covered services above the Members applicable copayment, coinsurance or deductible as reflected on this statement.

A 45 W21 Multiple Imaging procedure payment policy applies. The allowable amount for this service has been paid at 100%.

A 45 W21A Multiple Imaging procedure payment policy applies. The allowable amount for this service has been paid at 100%

A 45 W22 Multiple Imaging procedure payment policy applies. The allowable amount for this service has been paid at 50%


A 45 W31 CareCore Bundling agreement applies. The allowable amount for this service has been paid at 100%.







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A 45 A28 The adjustment on this claim represents a discounted amount for prompt payment.

A 45 A102 This claim has been reimbursed at UCR rates as the PCP made a referral to a non participating provider.

A 45 A102A Oxford received a referral for this service, and therefore it has been reimbursed at the contracted rate.

A 45 A20 This claim has been paid in accordance with our contractual arrangement with Advanced Provider Systems. Under this arrangement, Oxford's payment is considered payment in full and the Member is not responsible for any additional payment, beyond the applicable coinsurance/deductible.

A 45 A21 This claim has been adjusted to reflect the HMO DRG rate. This payment should be considered payment in full and the Member is not responsible for any additional payment, beyond the applicable coinsurance/deductible. .

A 45 A27 Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Medicare's allowed amount. Participating Providers may not balance bill Members for Covered Services in excess of the applicable co-pay, co-insurance, or deductible.

A 45 A27Z Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Medicare's allowed amount.

A 45 A32 The adjustment made on this claim reflects a retroactive increase in NY State DRG rates.

A 45 A32P This amount reflects an additional medical expense being paid to the provider for this claim.

A 45 A33 This claim has been adjusted in accordance with generally accepted insurance industry standards for assistant surgeon claims. Oxford's reimbursement on this claim represents 20% of the usual, customary and reasonable allowance for the surgical procedure(s) performed.

A 45 A33A This claim is adjusted in accordance with CMS’ (Centers for Medicare and Medicaid Services) reimbursement guidelines for assistant surgeon claims when the assistant surgeon is a physician. Oxford’s reimbursement on this claim represents 16% of the allowable amount for eligible surgical procedures

A 45 A33B This claim is adjusted in accordance with CMS’ (Centers for Medicare and Medicaid Services) reimbursement guidelines for assistant surgeon claims when the assistant surgeon is a health care professional other than a physician. Oxford’s reimbursement on this claim represents 14% of the allowable amount for eligible surgical procedures.

A 45 A36 The adjustment made on this claim indicates that payment was made at the short stay DRG rate for the services rendered.

A 45 A37 The payment reflected on this claim was issued at the contracted rate Oxford has negotiated with your facility. The Member is not responsible for any additional payment, beyond the applicable coinsurance/deductible.

A 45 A37A Payment adjusted at fair market value for services rendered. A 45 A37B PROVIDERS CONTRACT MAXIMUM HAS BEEN REACHED


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A 45 A42 Oxford's payment on this claim was reimbursed based on PHCP's fee schedule for network participating providers. Therefore, Oxford's payment is considered payment in full and the Member is not responsible for any additional payment, beyond the applicable coinsurance/deductible.

A 45 A45 As the provider of services you have accepted our payment as payment in full.

A 45 A45A This claim has been paid at the negotiated rate. A 45 A45B This claim is considered paid in full by Oxford. The Member is not

responsible for any additional payment beyond the applicable coinsurance/deductible requirements.

A 45 A45C As per the plan for open enrollment and the liquidation of HIP, you may not balance bill the member for charges other than applicable In-Network copayments or coinsurance for these services.

A 45 A45D This claim has been reimbursed at an In-Network rate as the provider was acting as the covering physician for the members regular participating physician. This is considered payment in full and the member is not responsible for any additional payment, beyond the applicable coinsurance/deductibles.

A 45 A45E This claim is considered paid in full by Oxford. The Member is not responsible for any additional payment beyond the applicable coinsurance/deductible requirements.

A 45 A45F This claim is considered paid in full by Oxford. The Member is not responsible for any additional payment beyond the applicable coinsurance/deductible requirements.

A 45 A45P This claim is considered "paid in full" by Oxford. The Member is not responsible for any additional payment beyond the applicable coinsurance/deductible requirements.

A 45 A46 The payment issued for this claim represents the amount payable per the applicable the Medicare fee schedule and must be accepted as payment in full. We are required to reimburse at the Medicare rate per our contract with the CMS. The Member is not responsible for any additional payment, beyond applicable costshares.

A 45 A46A Oxford paid this claim at the Medicare limiting charge amount as you are not a participating provider with Oxford's Medicare program and you do not accept Medicare assignment. The limiting charge amount is payment in full. The Member is not responsible for any additional payment, beyond applicable costshare.

A 45 A47 Oxford Health Plans participates with the First Health Network and has paid this claim according to the contracted rates. This payment is payment in full. The Member is not responsible for any additional payment, beyond applicable coinsurance/deductibles.

R 45 A5 An adjustment has been made to this claim to reflect an updated usual, customary and reasonable allowance for this procedure.

A 45 A54 Oxford's payment on this claim represents payment for an Oxford Healthy Start Member and reflects the Medicaid DRG rate.

A 45 A56 Oxford's payment on this claim was issued at the Consulting Specialists fee schedule for the services performed. As a participant in Oxford's Healthy Start Medicaid Program, Oxford's payment is considered as payment in full.

R 45 A57 Claim paid at the lesser of Medicaid Paid or Billed Charges.


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A 45 A61 Reimbursement for Assistant Sugeons is at 20% of the Medicaid Maximum Allowable Fee according to the Medicaid Management Information System's Manual.

A 45 A63 Referred by a participating Oxford provider. All non-participating providers providing medical services to Oxford's Title XIX members are reimbursed at 100% of the Medicaid rates as defined State guidelines.

A 45 A64 This service was paid at the Multiplan contracted rate. Based on our agreement the member can only be balance billed for the applicable copay, deductible or coinsurance. The member may not be billed for any amount beyond the difference between the Multiplan rate and what Oxford has paid.

A 45 A64A This claim was paid in accordance with the InterPlan Discount Rate Agreement.

A 45 A64B This claim was paid in accordance with the PPONext Discount Rate Agreement.

A 45 A64C This claim was paid in accordance with the Ohio Preferred Network Discount Rate Agreement.

A 45 A64D This claim was paid in accordance with the Preferred Plan Discount Rate Agreement.

A 45 A64E This service was paid at the MultiPlan contracted rate. Based on our agreement the member can only be balance billed for the applicable copayment, deductible, or coinsurance. The Member may not be billed for any amount beyond the difference between MultiPlan rate and what Oxford has paid.

A 45 A64F This service was paid at the Three Rivers Provider Network/Managed Care Strategies (TRPN/MCS) contracted rate. Based on our agreement the member can only be balance billed for the applicable copayment, deductible, or coinsurance. The Member may not be billed for any amount beyond the difference between TRPN/MCS rate and what Oxford has paid.

A 45 A64G With the assistance of Multiplan, this claim has been processed according to a signed fee agreement negotiated with the provider.

A 45 A7 Oxford has received a referral from the Members' Primary Care Physician; this claim has been adjusted accordingly.

A 45 A79 This claim has been paid at 100% of the usual, customary and reasonable allowance for the services provided. Please contact Provider Services if you have any questions concerning the processing of this claim.

A 45 A79M This claim has been paid at 100% of the usual, customary and reasonable allowance for the services provided. Please contact Provider Services if you have any questions concerning the processing of this claim.

A 45 A83 The payment of this claim has been adjusted to reflect co-surgery services were performed.

A 45 A83A The payment of this claim has been adjusted to reflect team surgery services were performed.

A 45 D90A This service has been processed according to your fee arrangement. The member is not responsible for this charge.

A 45 A37F The claim was paid at the contracted rate. You have no financial responsibility outside of any applicable deductible, coinsurance, or copayment


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A 45 A37E The claim was paid at the contracted rate. You have no financial responsibility outside of any applicable deductible, coinsurance, or copayment

A 45 A88C This service has been paid in accordance with the provider's Beech Stret Supplemental Network agreement. The member can only be balanced billed for the applicable copay, deductible, coinsurance, or non-covered chages. Please call 1-888-249-4380 with questions regarding the rate.

A 45 A88D This service has been paid in accordance with the provider's PPONext agreement. The member can only be balanced billed for the applicable copay, deductible, coinsurance, or non-covered chages. Please call 1-888-249-4380 with questions regarding the rate.

A 45 A37H This claim line has been adjustment to represent inpatient days that are not supported due to lack of clinical information. This adjustment is for informational purposes only as the claim was paid at the appropriate DRG Contracted rate.

A 45 TCUT An adjustment has been made to this claim to reflect an updated usual, customary and reasonable allowance for this procedure.

A 49 D1A The treatment of routine foot care including the reduction of nails, corns and callouses is not a covered benefit under this plan.


A 49 T319 The treatment of routine foot care including the reduction of nails, corns and callouses is not a covered benefit under this plan.

A 49 T320 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

A 50 D35C Payment of this claim has been denied due to lack of medical necessity. A 50 D35G According to our records, this is the Member's first visit seeking

chiropractic care. It is rare that a visit at the level and amount of services billed would be appropriate to treat the musculoskeletal system. On that basis, we have reimbursed for an initial office visit in accordance with our payment guidelines. However, any evaluation and management services, as well as multiple manipulations and/or modalities above the normal utilization require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary (this includes any additional chiropractic services rendered). If you or the Member believe the services as billed were medically appropriate, we need to review medical documentation to confirm that the level of service billed matches the service provided. Medical documentation includes: (1) office notes, SOAP (subjective, objective, assessment, plan/procedure) notes with exam narratives, or equivalent notes which show the Member's condition and progress, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the level of service billed matches the service provided. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45 days, to: TRIAD Healthcare, Inc., P.O. Box 905, Plainville, CT 06062-0905. (Please note that federal law requires you to supply the Member with medical notes upon the Member's request.) If notes have been sent directly to TRIAD, you do not need to resubmit them in response to this request and will receive a written decision within 30 days from TRIAD's receipt of the notes. If you would like to confirm that


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TRIAD has received the notes, please call TRIAD at 800-409-9081.

A 50 D38 The service was denied after review by an Oxford Medical Director. A separate letter was sent explaining the basis for the denial. If you would like to appeal the Medical Director's determination, you must follow the appeal rights provided in the separate determination letter and submit an appeal within 180-days from receipt of that letter. If you have any other questions or appeals concerning the processing of this claim, please follow the claims review process shown on the last page of this Explanation of Benefits.

A 50 D38A This claim has been denied as the requested medical information has not been provided.

A 50 D38E This claim has been denied as medical necessity has not been demonstrated; criteria not met after review by Orthonet.

A 50 D38F The billed service was denied after review by an Oxford Chiropractic Clinical Reviewer. A separate letter was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180 days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business Member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60 days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance Advice.

A 50 D38G Medical necessity has not been demonstrated. In order for Oxford to consider payment, please return this Explanantion of Benefits with medical documentation (i.e. care plans / office notes) to substantiate the services rendered.

A 50 T470 Medical necessity has not been demonstrated. In order for Oxford to consider payment, please return this Remittance Advice with medical documentation (i.e., office notes) to substantiate the services provided.

A 51 D10 This charge has been denied since it represents treatment of a pre-existing condition.

A 53 D60D According to the member certificate, providers are prohibited from treating family members.

A 54 D1L Assistant surgeon services are not warranted for the procedure performed.


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A 54 D2L All surgical procedures must be authorized in advance of providing the services. These services were denied because they were not authorized in advance. Please contact Provider Services if you have any questions concerning the processing of this claim. Please note, you are not allowed to balance bill the member for this service.

A 54 T404 Assistant surgeon services are not warranted for the procedure performed. A 54 TCCS Assistant surgeon services are not warranted for the procedure performed. A 54 TMNC These charges have been denied since they represent services which are

not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 54 TMPC These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 58 D21 The services billed on this claim have been denied since our records reflect that Out-of-Network benefits have been exhausted for the current plan year.

A 58 D27 The laboratory services performed have been denied because they were not performed by an Oxford Laboratory Network Provider. As an Oxford participating provider, all diagnostic laboratory testing should be forwarded to an Oxford Laboratory Network Provider. Any laboratory testing performed in your office is not eligible for reimbursement and cannot be billed to the member.

A 58 DC2 This claim shows a procedure code listed with an incorrect place of service. In order for Oxford Health Plans to consider payment on this claim, please resubmit this claim with the correct place of service for the listed procedure codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027. On future initial claim submissions please be sure to include the appropriate place of service for the billed procedure codes.

A 59 A30 This claim has been adjusted in accordance with generally accepted insurance industry standards for bilateral surgical claims. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amount is allowed for the subsequent procedure.

A 59 A31 This claim has been adjusted in accordance with generally accepted insurance industry standards for claims billed with multiple surgical procedures. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amountis allowed for any subsequent procedure.

A 59 A68 This claim has been adjusted to reflect Medicare reimbursement standards for claims with multiple surgical procedures. The primary procedure has been paid at 100% of the Medicare rate (according to CMS guidelines); and additional procedures have been paid at 50% of the Medicare rate.

A 59 A69 This claim has been adjusted in accordance with Medicaid standards for claims billed with multiple procedures. The full 100% of the Medicaid allowable rate for this region is provided for the primary procedure and 50% of the Medicaid allowable rate for any subsequent procedure(s)


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A 59 A70 This claim has been adjusted to reflect Medicare reimbursement standards for two surgical procedures. The primary procedure has been paid at 100% of the Medicare rate (according to CMS guidelines); and the secondary procedure has been paid at 50% of the Medicare rate.

A 59 A71 This claim has been adjusted in accordance with Medicaid standards for claims billed with bilateral surgical procedures. The full 100% of the Medicaid allowable rate for this region is provided for the primary procedure and 50% of the Medicaid allowable rate for any subsequent procedure(s).


A 59 T333 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.





A 59 T534 This claim has been adjusted in accordance with generally accepted insurance industry standards for bilateral surgical claims. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amount is allo

A 59 T536 This claim has been adjusted in accordance with generally accepted insurance industry standards for bilateral surgical claims. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amount is allo

A 59 TBLT This claim has been adjusted in accordance with generally accepted insurance industry standards for bilateral surgical claims. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amount is allowed for the subsequent procedure.

A 59 TBT2 This claim has been adjusted in accordance with generally accepted insurance industry standards for bilateral surgical claims. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amount is allowed for the subsequent procedure.

A 59 TMS1 This claim has been adjusted in accordance with generally accepted insurance industry standards for claims billed with multiple surgical procedures. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amountis allowed for any subsequent procedure.


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A 59 TMUL This claim has been adjusted in accordance with generally accepted insurance industry standards for claims billed with multiple surgical procedures. The full usual, customary and reasonable (UCR) allowance is provided for the primary procedure and 50% of the UCR amountis allowed for any subsequent procedure.

A 62 A87 Pre-certification is required after the 15th visit for chiropractic services rendered through 12/31/99. Please call 1-888-454-0620 when the 15th visit is completed if additional care is needed.

A 62 D13X The Member’s health benefits plan requires an authorization be obtained in advance of receiving this service. Medical necessity review is required for this study, which will include a review of your credentials. We need to review medical documentation related to the study (office notes, operative reports, results of available studies/tests, and any other relevant documentation) and information about your facility qualifications to render these services. Information about your qualifications must address the following: 1. Does your facility currently have a 64 slice CT scanner on site? If Yes, please note the Manufacturer 2. Does your facility have a lab director/Cardiac Imaging Specialist (CIS) that has performed 100 exams and interpreted 200 additional exams? If Yes, please list the CIS name. 3. Will a physician be on site for the performance of all CCTA exams? You or the Member must return a copy of this Remittance Advice Statement, and the requested information within 45 days to Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027. Although you do not participate with Oxford, if your facility meets our designation requirements for this study, you may become credentialed and avoid the qualification review portion of future medical necessity reviews. You may obtain our detailed designation criteria and the Professional Physician/Practice Assessment (PPPA) form at www.carecorecardiology.com. We will review completed PPPA forms sent to: Credentialing Department CareCore National 169 Myers Corners Road Wappingers Falls, NY 12590

A 62 D2B A portion of the Member's inpatient admission was denied. Services rendered during that period are denied as unauthorized.

A 62 T245 These services were formally denied because they wer not authorized in advance

A 62 T425 These services were formally denied because they wer not authorized in advance.

A 65 TSEM This claim has been ajdusted to reflect the correct procedure codes in accordane with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide

A 65 TRNR This claim has been ajdusted to reflect the correct procedure codes in accordane with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide


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A 78 D2A These dates of services were formally denied because Oxford was not notified of the correct dates of service. These days will remain denied unless the hospital can submit proof that Oxford was notified of the updated dates of service.

A 85 A5B An adjustment has been made on this claim to reflect interest payment. A 85 A73 Because this claim took more than 45 days to process, this payment

includes 15% interest, as required by Connecticut state law. A 85 A73A Because this claim took more than 45 days to process, this payment

includes 12% interest, as required by New York state law. A 85 A73B Because this claim took more than 60 days to process, this payment

includes 10% interest, as required by New Jersey state law. A 85 A73C Because this claim took more than 60 days to process, this payment

includes 10% interest, as required by Pennsylvania state law. A 85 A73D Because this claim took more than 60 days to process, this payment

includes 10% interest, as required by New Hampshire state law. A 85 A74 The prompt payment interest rate as deemed by Medicare has been added

to the 100% Medicare allowable rate reimbursed to you. This rate is 6.75% currently and is applied to CLEAN paper and electronic claims that have not been paid by the 30th day after the date of receipt. This approved rate by the Secretary of the Treasury as published semi-annually in the Federal Register applies to unaffiliated providers only for authorized services and items for Oxford Medicare Advantage(SM) plan Members only.

A 85 A76 The prompt payment interest rate as deemed by Medicare has been added to the charged amount for this procedure. This reimbursement rate has added the 6.375% interest rate as approved by the Secretary of the Treasury as published semi-annually in the Federal Register. The current interest rate applies to CLEAN paper and electronic claims that have not been paid by the 30th day after the date of receipt by unaffiliated providers only. This applies to authorized services and items for Oxford Medicare Advantage(SM) plan Members only.

A 85 A77 The prompt interest rate as deemed by Medicare has been added to the accepted Medical Management Department rate for this procedure or item. The current interest rate is 6.375% and is applied to CLEAN paper and electronic claims have not been paid by the 30th day after the date of receipt. This approved rate by the Secretary of the Treasury as published semi-annually in the Federal Register applies to authorized services for Members of Oxford Health Plan's Medicare Advantage Plan provided by unaffiliated providers only.

A 91 A85 PMT Approved by Pharmacy Services Manager A 95 A29 Benefits on this claim were reduced because Oxford was not notified in

advance of these services. Pre-certification is required for all elective procedures. Oxford must be notified within 48 hours of any urgent or emergent procedures.

A 95 A29A Benefits on this claim were reduced because Oxford was not notified in advance of these services. Pre-certification is required for all elective procedures. Oxford must be notified within 48 hours of any urgent or emergent procedures.


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A 95 A29M Benefits on this claim were reduced because Oxford was not notified in advance of these services. Pre-certification is required for all elective procedures. Oxford must be notified within 48 hours of any urgent or emergent procedures.

A 95 A66 A penalty of up to $500 has been applied against this claim in accordance with the terms of coverage under the Princeton University Point of Service Plan. This plan requires pre-certification in advance of any elective hospitalization or surgical procedure by calling Oxford's Medical Management Department. Additionally, Oxford requires notification within 48 hours of an emergency hospital admission. If you have questions, please refer to your Certificate of Coverage, or contact Princeton's Customer Service Center (800-303-9905).

A 95 A67 A penalty of up to $500 has been applied against emergency related claims in accordance with the terms of coverage under the Princeton University Point of Service Plan. This plan requires that Oxford's Medical Management Department is notified within 48 hours of receiving treatment for a true medical emergency. Emergent care is defined as treatment, which if not immediately received, could result in the physical impairment or death of a member. If you have questions, please refer to your Certificate of Coverage, or contact Princeton's Customer Service Center (800-303-9905).

A 95 A81 Because Oxford did not receive pre-certification for this outpatient service, a $200 penalty has been applied. Under the US Surgical Point of Service plan, all elective hospitalizations/elective surgeries require pre-certification at least 14 days in advance (or as soon as possible) through Oxford's Medical Management Department (800-385-9055).

A 95 A82 Because Oxford did not receive pre-certification for this inpatient service, a $400 penalty has been applied. Under the US Surgical Point of Service plan, all elective hospitalizations/elective surgeries require pre-certification at least 14 days in advance (or as soon as possible) through Oxford's Medical Management Department (800-385-9055).

A 95 D2G This claim is being paid at a reduced rate because Oxford was not notified on hospital census about the inpatient admission.

A 96 D1 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 96 D13O Surface EMG is not a covered procedure. A 96 D13W Cosmetic services are not covered. If you feel the service was medically

necessary, please resubmit the claim with medical records or other supporting data, and Oxford Health Plans will re-review. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45-days, to: Oxford Health Plans, Inc., Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027 (Please note that federal law requires the provider to supply a patient with medical notes if requested.)

A 96 D1E The removal of skin tags is considered a cosmetic procedure and is not a covered benefit under this plan.

A 96 D1F The services indicated on this claim have been determined to be cosmetic in nature and are not covered under this plan. Cosmetic procedures are performed to alter the natural appearance of the individual and not to treat a specific medical condition.


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A 96 D1J The treatment of alopicea (hair loss) is considered a cosmetic procedure and is not a covered benefit under this plan.

A 96 D1N Oxford does not coordinate payment on claims totaling less than $50.00 for NJ small and individual plans.

A 96 D1P This service/claim is denied in accordance with the maximum age limit per state mandate for coverage for infertility benefits.

A 96 D35D Surface EMG is not a covered procedure A 96 D36 Oxford considers reimbursement of the ambulance attendant(s), supplies

and the first 30 miles one way, reflected in the fee paid for in the ambulance service.

A 96 D45 This claim has been denied since the services performed are not covered under Medicaid and is not reimbursable under the Healthy Start Program. If you should have any questions, please refer to your MMIS Provider Manual or contact Member Services at 800 444-2413 for assistance.

A 96 D46 This service has been denied because it is not a covered benefit under SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228

A 96 DU3 Oxford Health Plans is a United Healthcare subsidiary. It has been noted that these are separately billed late charges. A resubmission of the full bill with the inclusive late charges is required in order to re-evaluate this claim for any additional payment. Please resubmit this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 96 T413 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 96 T480 This code is part of the Curascript contract and is paid to Curascript only. This code is not payable to a Curascript network provider.

A 96 T513 The services indicated on this claim have been determined to be cosmetic in nature and are not covered under this plan. Cosmetic procedures are performed to alter the natural appearance of the individual and not to treat a specific medical condition.







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A 96 T616 Chest x-ray is not covered as a preventive benefit. A 96 TBC2 The services indicated on this claim have been determined to be cosmetic

in nature and are not covered under this plan. Cosmetic procedures are performed to alter the natural appearance of the individual and not to treat a specific medical condition.

A 96 TCA1 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 96 TCCS Assistant surgeon services are not warranted for the procedure performed. A 96 TCTA This service/claim is denied in accordance with the maximum age limit per

state mandate for coverage for infertility benefits. A 96 TMNC These charges have been denied since they represent services which are

not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 96 TMPC These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 96 TNJA This service/claim is denied in accordance with the maximum age limit per state mandate for coverage for infertility benefits.

A 96 TNJI This service/claim is denied in accordance with the maximum age limit per state mandate for coverage for infertility benefits.

A 96 TNYC Cosmetic services are not covered. If you feel the service was medically necessary, please resubmit the claim with medical records or other supporting data, and Oxford Health Plans will re-review. You or your provider should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45-days, to: Oxford Health Plans, Inc., Attn: Corrected/Resubmitted Claims, P.O. Box 7017, Bridgeport, CT 06601-7017 (Please note that federal law requires your provider to supply you with medical notes upon your request.)

A 96 TPNC This service has been denied because it is not a covered benefit under SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228.

A 96 TROM This service has been denied because it is not a covered benefit under SecureHorizions(R)/Oxford plans. For additional information about the benefits please refer Members to their Evidence of Coverage or contact Customer Service at (800) 234-1228.

A 96 TWG1 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 97 D11 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 D11A Oxford's reimbursement for office services includes performing this procedure and thus it is not payable as a separate item.


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A 97 D11C In accordance with generally accepted medical coding guidelines, this procedure is considered a component of the major surgical procedure performed and is not reimbursable as a separate item. This service is only considered a covered benefit though the primary surgical allowance.

A 97 D11T This service is not eligible for reimbursement as a separate procedure as it is considered part of the URN Global Case Rate and is therefore considered inclusive. The member is only responsible for the applicable copay, deductible or coinsurance

A 97 D11U This service is not eligible for reimbursement as a separate procedure as it is considered part of the URN Global Case Rate and is therefore considered inclusive. The member is only responsible for the applicable copay, deductible or coinsurance.

A 97 D14 This service has already been reimbursed as a part of the fee paid to the hospital for hospital based services.

A 97 D14A Part of global payment paid to provider. A 97 D14B This service has been denied as it is part of the global payment already

made to our Outside Pharmacy Vendor A 97 D14M Baby claim paid under mom's claim A 97 D14T Denied inclusive to the transplant. A 97 D5 Allergy serum covered with Office Visit A 97 D96 This service is not being reimbursed as billed as it is either considered part

of a more global procedure or reflects the correct procedure code in accordance with guidelines set forth in the American Medical Association’s Current Procedural Terminology (CPT) guide.

A 97 DU3 Oxford Health Plans is a United Healthcare subsidiary. It has been noted that these are separately billed late charges. A resubmission of the full bill with the inclusive late charges is required in order to re-evaluate this claim for any additional payment. Please resubmit this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027.

A 97 T345 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive. Please do not balance bill the member.

A 97 T346 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.







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A 97 T460 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.
















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A 97 TAHW This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TBND This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TCH4 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TCOD This service is ineligible for reimbursement as a separate procedure under Oxford policy, which is based upon Medicare's Correct Coding initiative (CCI). According to CCI, this procedure may not be billed with the other procedure(s) performed and is not eligible for separate reimbursement. Participating providers may not balance bill the member for this service.

A 97 TCP1 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TCPS This service is ineligible for reimbursement as a separate procedure under Oxford policy, which is based upon the Current Procedural Terminology (CPT) guidelines and other general industry guidelines. According to these guidelines, this service is considered part of the comprehensive procedure that was performed and is not payable separately. Participating providers may not balance bill the member for this service.


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A 97 TCS3 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TCS4 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TDSG This service is ineligible for reimbursement as a separate procedure under Oxford policy, which is based upon the Current Procedural Terminology (CPT) guidelines and other general industry guidelines. According to these guidelines, this evaluation and management service is considered a component of the major surgical procedure performed and is not reimbursable as a separate item. Reimbursement for this service is included in the reimbursement for the comprehensive surgical procedure that was performed. Participating providers may not balance bill the member for this service.

A 97 TGO1 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TGSP This service is ineligible for reimbursement as a separate item under Oxford policy, which is based upon Medicare's Correct Coding initiative (CCI) and other general industry guidelines. This service is considered a component of the major surgical procedure performed and is not reimbursable as a separate item. Reimbursement for this service is included in the reimbursement for the comprehensive surgical procedure that was performed. Participating providers may not balance bill the member for this service.

A 97 THC2 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TIV2 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive

A 97 TLAB This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TLB1 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A 97 TLB2 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TMC1 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TMCP This service is not being reimbursed as billed as it is either considered part of a more global procedure or reflects the correct procedure code in accordance with guidelines set forth in the American Medical Association?s Current Procedural Terminology (CPT) guide.

A 97 TNTI This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.


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A 97 TOCP This service is not being reimbursed as billed as it is either considered part of a more global procedure or reflects the correct procedure code in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide

A 97 TPAR This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A 97 TPVC This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TQC1 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive. Please do not balance bill the member.

A 97 TQCI This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TRA3 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TRA4 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TRAN This service is not being reimbursed as billed as it is either considered part of a more global procedure or reflects the correct procedure code in accordance with guidelines set forth in the American Medical Association’s Current Procedural Terminology (CPT) guide.

A 97 TREC This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 97 TSSV This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 100 A15 This claim has been adjusted to correct the assignment of benefits indicated on the claim form.

A 100 A25 This claim has been adjusted to correct the assignment of benefits. Payment is now being issued to the subscriber.

A 101 A50 This claim is under review. A partial payment has been rendered. Once the review is completed, additional payment may be issued.

A 101 D8 Oxford does not reimburse pre-natal care on a visit by visit basis. Please submit a claim for total maternity care including pre-natal visits after the delivery. Charges for diagnostic laboratory and radiological services administered during a pregnancy may be billed prior to delivery under a separate claim.

A 101 TMAT Oxford does not reimburse pre-natal care on a visit by visit basis. Please submit a claim for total maternity care including pre-natal visits after the delivery. Charges for diagnostic laboratory and radiological services administered during a pregnancy may be billed prior to delivery under a separate claim.

A 102 A3H Deductible amount has been adjusted


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A 102 A86 This claim has been adjusted and is being reimbursed on an exception basis. Generally, the services described are excluded under this contract and this payment does not ensure reimbursement for future occurences.

A 102 A8A This claim was paid per clinical review A 102 A8B The service you rendered was reviewed by an Oxford Clinical Resource

Specialist and the claim was paid accordingly. A 102 A8C The service you rendered was reviewed by an Oxford Medical Director and

the claim was paid accordingly. A 104 A6 This claim has been adjusted to reflect the correct physician withhold

amount required on this claim. A 109 D40A Coverage under your plan for prescription drugs is administered through

Oxford's Pharmacy Benefit Manager and is not considered a medical benefit. We are returning your billing statement to you along with a pharmacy claim form. Please complete the pharmacy claim form, attach your prescription receipts and mail them directly to the Pharmacy Benefit Manager for processing. If you should have additional questions regarding your prescription drug coverage, please contact Pharmacy Customer Service at 800 905 0201.

A 109 D44A Claims should be submitted to CareCore National formerly known as New York Medical Imaging.

A 109 D20B This claim is being sent to ACN Group, our chiropractic delgate, for processing. Future chropractic claim(s) must be submitted to : ACN Group, PO Box 5800, Kingston, NY 12402-5800.

A 109 D20C This claim is being sent to ACN Group, our chiropratic delegate for processing. Any chiropractic claims with DOS 03/01/08 must be submitted to ACN Group, PO Box 5800, Kingston, NY 12402-5800.

A 109 D47 SUBMIT YOUR CLAIM TO MONTEFIORE MEDICAL GROUP FOR PAYMENT AT: MONTEFIORE CMO, 200 CORPORATE DRIVE, YONKERS, NY 10701

A 109 D52A This member is enrolled in Medicare certified hospice. Please bill traditional Medicare for payment.

A 109 D52B Claims for new NCDs determined to be significant should be forwarded to the applicable Medicare Intermediary/Carrier for reimbursement.

A 109 D56 THESE SERVICES HAVE BEEN DENIED AS THEY HAVE BEEN DETERMINED TO BE FOR MAINTENANCE THERAPY AND ARE IN EXCESS OF THE CONTRACTUAL LIMIT.

R 109 D56 THESE SERVICES HAVE BEEN DENIED AS THEY HAVE BEEN DETERMINED TO BE FOR MAINTENANCE THERAPY AND ARE IN EXCESS OF THE CONTRACTUAL LIMIT.

A 109 D59 This claim has been denied since our records reflect that this claims was previously processed by your prior carrier, PlanData. Please contact PlanData's Customer Service Department or your corporate benefits administrator with any questions you have on this claim.

R 109 D59 This claim has been denied since our records reflect that this claims was previously processed by your prior carrier, PlanData. Please contact PlanData's Customer Service Department or your corporate benefits administrator with any questions you have on this claim.

A 109 D60C According to Oxford eligibility requirements, individual was not eligible for coverage at time of enrollment.


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A 109 D61 The date of service on this claim pre-dates coverage under the Oxford program. Because of this, you must re-submit this claim to your Benefit Administrator at 380 Middlesex Avenue, Cataret, NJ 07008, for further handling.

R 109 D61 The date of service on this claim pre-dates coverage under the Oxford program. Because of this, you must re-submit this claim to your Benefit Administrator at 380 Middlesex Avenue, Cataret, NJ 07008, for further handling.

A 109 D65C Oxford Health Plans has received your dental claim, however, dental claims are processed by our dental claims processing unit in Eatontown, NJ. Please send the claim to the following address: Oxford Health Plans, P>O> Box 1168, Eatontown, NJ 07724-0609

A 109 D66 Prepaid Partnership. Claim sent to Yale New Haven Health Services MSO for processing.

A 109 D68 Please send your claim to : FPA Medical Management Inc. 5835 Blue Lagoon Drive, Miami FL 33126

A 109 D83G Goldman Sachs responsible for lab services A 109 D83M This is a domestic suppression claim. This benefit is self-funded by the

hospital therefore Oxford Health Plans is not responsible for payment. A 109 D83N Member is part of Nyack Hospital. This benefit is self-funded by Nyack

Hospital and therefore Oxford is not responsible for payment. A 109 DJ1 Oxford Health Plans is a United Healthcare subsidiary. Please submit this

home infusion or specialty medicine services claim directly to Ancillary Care Management at ACMCENTRAL.com for repricing.

A 109 DJ2 Oxford Health Plans is a United Healthcare subsidiary. Please submit this home infusion or specialty medicine services claim directly to Ancillary Care Management at ACMCENTRAL.com for repricing.

A 109 DURN Claim should be submitted by your provider directly to United Resource Networks (URN) a division of United HealthCare Services Inc. Once URN reviews the case and services, payment will be based upon your providers "Patient Specific Network Access Agreement" with URN. Submission address is U.R.N., P.O. Box 30758, Salt Lake City, UT 84130.

A 109 TDS1 This is a domestic suppression claim. This benefit is self-funded by the hospital therefore Oxford Health Plans is not responsible for payment.

A 109 TDS2 This is a domestic suppression claim. This benefit is self-funded by the hospital therefore Oxford Health Plans is not responsible for payment.

A 109 TDSU This is a domestic suppression claim. This benefit is self-funded by the hospital therefore Oxford Health Plans is not responsible for payment.

A 111 D21E Medicare Opt Out Provider: Payment for services prohibited by Medicare law. Balance billing is allowed.

A 119 A104A No funds available in benefit bank, claim will be processed if funds become available.

A 119 A72 This payment represents reimbursement for a supplemental medical expense plan. Benefits under this plan are limited to a maximum annual reimbursement of $5,000 per family per year.


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A 119 A7B This charge has been adjusted because it exceeds the maximum benefit available under your plan for chiropractic services. Chiropractic services are covered at 50% of a maximum daily chargeof $40 with the total of all eligible charges not to exceed $500 per contract year. The maximum of $500 includes any amounts for chiropractic servicesthat have been applied to the annual deductible.

A 119 A7C This claim has been adjusted since the maximum covered benefit for chiropractic treatment has been exceeded for the current plan year.

A 119 A7D This claim has been adjusted since the maximum covered benefit for mental health services has been exceeded for this current calendar year.

A 119 A7E These services have been adjusted since they exceed the maximum benefits provided under your plan. Please refer to your certificate of coverage or contact Member Services if you have further questions.

A 119 A98A The Member's Outpatient Benefit has been exhausted. He/She is currently accessing his/her Inpatient Benefit. For every two Outpatient Visits, an Inpatient Benefit will be reduced by one day.

A 119 D11D The maximum allowed number of modalities per session has been exceeded on this claim. Oxford allows no more than three modalities per date of service unless documentation is sent to support additional treatment. The member can not be billed for these denied services.

A 119 D7B This charge has been denied because it exceeds the maximum benefit available under your plan for chiropractic services. Chiropractic services are covered at 50% of a maximum daily chargeof $40 with the total of all eligible charges not to exceed $500 per contract year. The maximum of $500 includes any amounts for chiropractic servicesthat have been applied to the annual deductible.

A 119 D7E These services have been denied since they exceed the maximum benefits provided under your plan. Please refer to your certificate of coverage or contact Member Services if you have further questions.

A 119 D7X COB Max Benefit Exceeded A 119 T372 These services have been denied since they exceed the maximum benefit

provided under your plan. Please refer to your certificate of coverage or contact member Services if you have any further questions.

A 119 T386 These services have been denied since they exceed the maximum benefit provided under your plan. Please refer to your certificate of coverage or contact member Services if you have any further questions.




A 119 T483 The maximum allowed number of modalities per session has been exceeded on this claim. Oxford allows no more than three modalities per date of service unless documentation is sent to support additional treatment. The member can not be billed for these denied services.


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A 119 TDEX These services have been denied since they exceed the maximum benefit provided under your plan. Please refer to your certificate of coverage or contact member Services if you have any further questions.

A 119 TPOD These services have been denied since they exceed the maximum benefit provided under your plan. Please refer to your certificate of coverage or contact member Services if you have any further questions.

A 121 A22 This claim was billed as an HMO claim. However, payment has been issued based on the commercial rate coinciding with this Member's indemnity insurance coverage.

A 121 A99 Additional information received A 123 A95 Partial refund received and applied. A 123 D95 Refund received and applied to claims. A 125 A103 Although the claim was authorized as an inpatient service, it was billed as

an outpatient service. We are paying the claim as billed. However, future payments may be denied or reduced unless Oxford is notified in advance that the service setting has chang

A 125 A109 The claim you submitted appears to indicate dosage in lieu of units in the units field. Due to the various methods that this drug is dispensed, we cannot determine if the units billed are appropriate. If you disagree with units that were paid on this claim, please resubmit this claim with the corresponding NDC number to: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, CT 06601-7027.

A 125 A37D To appeal DRG, please send medical notes to: Oxford Health Plans Inc. Attention: Debora Scanlon P.O. Box 7078 Bridgeport, CT 06611

A 125 A37G Reviewed Medical Notes, DRG adjusted A 125 AP28 For processing purposes, this service line has been recoded with a single

unit A 125 D83 This claim has been denied because it was either billed in error, the

charges have been canceled or the services were not actually performed. This information was received directly fromthe provider.

A 125 DF01 This procedure appears to have been billed excessively on this date of service. Please submit this Explanation of Benefits with any medical records which support the medical necessity ofthis service to the Correspondence Department, 7120 Main Street, Trum

A 125 DP47 This service line submitted with multiple units will be recoded to multiple service lines to separate the units






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A 125 T523 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide





A 125 TAN2 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 125 TAN3 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 125 TBEN This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 125 TCS2 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 125 TNPT This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 125 TVIS This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 133 A35 This claim is under review. A partial payment has been rendered. Once the review is completed, additional payment may be issued.

A 133 D58A Your claim has been received and is being processed A 137 A32A This amount reflects Oxford's payment of the New York State assessment

for bad debt and charity care and is not included in the total amount paid to you on this claim.

A 137 A32T This amount reflects Oxford's payment of the New York State assessment for bad debt and charity care and is not included in the total amount paid to you on this claim.

A 137 A52 Oxford's payment on this claim is for a Member who is covered under a self-insured benefits plan. The 11% surtax does not apply to self-insured groups and the surtax has not been included in the calculation of this claim.

A 137 P1 All or a part of this claim amount has been used to recover your portion of your partnership's deficit.


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A 137 BDC1 Claim has been reevaluated for the NY Bad debt and charity surcharge that has been recalculated and paid to the state. There is no additional member liability on this claim. If you have any questions please contact the provider service area.

A 140 A1 This claim has been adjusted to reflect Medicare reimbursement standards for claims with multiple surgical procedures. The primary procedure has been paid at 100% of the Medicare rate (according to CMS guidelines); and additional procedures have been paid at 50% of the Medicare rate. NEEDS CORRECTION BUT CSR WILL NOT ALLOW: This claim has been adjusted and now reflects the patient's correct member identification number.

A 142 A55 Oxford has not issued any payment for this claim since the services performed are covered under the monthly capitation payment issued to your office for Oxford HealthyStart Medicaid Members.

A 143 D40B Your claim has been received and will be forwarded to your Pharmacy Benefit Manager (PBM) for processing.

A 143 D54 For Healthy Start members only - this service was reimbursed to your facility by consulting Health Care Services (CHCS); therefore, Oxford Health Plans regards this claim as a duplicate to the original claim already paid by CHCS.

A 143 Z545 A claim for this procedure has been forwarded to OrthoNet LLC for processing

A 143 Z546 A claim for this procedure has been forwarded to OrthoNet LLC for processing

A 143 Z547 A claim for this procedure has been forwarded to Triad for processing. A 148 D13N Oxford is unable to pay for these services because the servicing provider is

not listed on the submitted claim. To abide by CMS regulations, it is required that a claim contain no defect or impropriety which prevents timely payment. Please submit a new "clean" claim to the address below. Oxford Health Plans, PO Box 7082, Bridgeport, CT 06601-7082

A 148 D21D CMS prohibits payment directly to the Physician Assistant. To be proc essed, the claim must be submitted by the Supervising Physician.

A 150 A78 The payment of this claim has been adjusted after being reviewed by Oxford's dental consultant.

A 150 A8L Claim submitted for inpatient services has been reimbursed per the DRG determined to be appropriate based on Oxford’s Clinical Claims Review Unit’s review of medical notes.

A 150 D1K These services have been denied per review by our dental consultant. A 150 TGNF CPT code billed is not substantiated by the medical documentation

submitted. A 150 TGNM CPT code billed is not substantiated by the medical documentation

submitted. A 165 A101 An Oxford referral was not received from the PCP for this participating

specialist claim. Therefore the claim was reimbursed at a lower rate and the Member is responsible for any applicable deductible or coinsurance.



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A 170 TCS1 Primary Care Physicians are not eligible to receive reimbursement for services usually performed by Consulting Specialists in the Oxford network of providers. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to a secondary insurance carrier that the patient may have.

A 171 D27A This laboratory does not qualify for In-Office payment. A 171 T558 This service has already been reimbursed as a part of the fee paid to the

hospital for hospital based services. A 172 A56 Oxford's payment on this claim was issued at the Consulting Specialists fee

schedule for the services performed. As a participant in Oxford's Healthy Start Medicaid Program, Oxford's payment is considered as payment in full.

A 175 D13Q Oxford is unable to provide payment at this time based on the information that has been submitted. Please resubmit your claim with the product name, followed by a valid National Drug Code (NDC) number along with the strenght and quantity of the drug that was provided on the date of service billed.

A 181 A13 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 181 A13A This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 181 A23 This claim has been adjusted and now reflects the correct date(s) of service.




A 181 T521 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Associaton's Current Procedural Terminology (CPT) guide.


A 181 TMX4 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A 183 A102 This claim has been reimbursed at UCR rates as the PCP made a referral to a non participating provider.

A 183 A34 This claim has been paid as an HMO benefit on an exception basis since the Member was referred to this non-participating provider by an Oxford Participating Provider. Future visits to non-participating providers will not be covered as an HMO benefit unless authorized in advance by Oxford.


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A 183 A62 Referred by a participating provider. All non-participating providers providing medical services to SecureHorizons?/Oxford members are reimbursed at the applicable Medicare rate.

A 185 D12 This service is only covered when performed by a licensed medical physician.

A 185 D19 These services have been denied since the provider has been deemed to be ineligible to perform these services under the terms of your plan.

A 185 D19B This service has been denied since it represents services which fall outside the scope of the provider's license. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to any secondary insurance carrier that the patient may have.

A 185 D19C Oxford does not cover services performed by naturopathic physicians, homeopathic physicians, unlicensed providers, religious figures, nurse anesthetists, physician assistants and providers who are related to the patient. This charge has been denied because it appears that the services were rendered by one of the above.

A 185 T303 These services have been denied since the provider has been deemed to be ineligible to perform these services under the terms of your plan.




A 185 T395 This service has been denied since it represents services which fall outside the scope of the provider's license. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to any secondary insurance carrier that the patient may have.




A 185 T462 These services have been denied since the provider has been deemed to be ineligible to perform these services under the terms of your plan



A 185 T551 This procedure has been denied because the provider is not privileged to perform this service.




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A 185 TAN1 These services have been denied since the provider has been deemed to be ineligible to perform these services under the terms of your plan.

A 185 TANM This service has been denied since it represents services which fall outside the scope of the provider's license. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to any secondary insurance carrier that the patient may have.

A 185 TBD1 This procedure has been denied because the provider is not privileged to perform this service.

A 185 TBD2 This procedure has been denied because the provider is not privileged to perform this service.

A 185 TBDB This procedure has been denied because the provider is not privileged to perform this service.

A 185 TESW This service is only covered when performed by a licensed medical physician.

A 185 TOST This service has been denied since it represents services which fall outside the scope of the provider's license. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to any secondary insurance carri


A 192 A100 This inpatient claim was incorrectly authorized as an outpatient service. Oxford is paying the claim as billed, however future payments may be reduced or denied if Oxford is not notified of a change in service setting before the service is rendered.

A 192 A107 OAG’s Health Care Consumer Help Hotline, 1-800-771-7755) Option # 3) The Hotline Staff is available to assist consumers with claim/appeals.

A 192 A108 Paid in accordance with the Member benefit A 192 A120 Thank you for your attachment, it has been received. A 192 A18A If additional reimbursement is warranted, please resubmit with

corresponding invoice A 192 A19B Effective 10/1/07, provider mut meet requirements in Cardiac CT

screening policy at www.oxhp.com. A 192 A38 This claim has been adjusted based upon our receipt of documentation

confirming full-time student status of this Member. A 192 A5F Adjusting Triad claim line. A 192 A5J Adjusting line for payment. A 192 A5K This claim has been adjusted to reimburse submitted charges. A 192 D11B This service code is only billable 1 time within a 30 day time frame from

the previous date of service it was billed per the American Medical Association Guidelines.


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A 192 D13Y In order for this study to be approved for payment as medically necessary, the study must meet clinical criteria for pre-certification AND be conducted by a provider who is designated as a Cardiac Imaging Specialist. Please refer to www.carecorecardiology.com to see our facility requirements. If your facility meets our requirements, please forward the Professional Physician/Practice Assessment (PPPA) to the address for review: Credentialing Department - CareCore National - 169 Myers Corners Road - Wappingers Falls, NY 12590. If your facility has already met our facility requirements, please forward confirmation of your approved status to Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027 and the claim will be re-processed.

A 192 RCRS Member is active with CRS (Cancer Resource Services). Please re-submit this claim directly to CRS for pricing. If you have any questions regarding this claim, please contact our Provider Services Department.

A 192 RF20 Arbor Healthcare refund received and applied to claims. A 192 RF3 OMNI refund received and applied to claims. A 192 T456 This service is not eligible for reimbursement as a separate procedure as it

is considered part of the more global procedure that was performed and is therefore considered inclusive.

A 192 T533 This service code is only billable 1 time within a 30 day time frame from the previous date of service it was billed per the American Medical Association Guidelines.

A 204 D1B The treatment of infertility, including any medications and or corrective procedures performed is not a covered benefit under this plan.

A 204 D1C Acupuncture is not a covered benefit for the treatment of any medical condition or diagnosis under this plan.

A 204 D1D Durable medical equipment, including wheelchairs, canes and walkers are not a covered benefit under this plan.

A 204 D1G Examinations for the purpose of prescribing eyeglasses, contact lenses, visual corrective appliances or for refractive conditions are not covered benefits under this plan.

A 204 D1H The cost of medical supplies, including syringes, crutches and bandages are not a covered benefit under this plan.

A 204 D1I Dental care including office care, diagnostic x-rays and surgical procedures is not a covered benefit under this plan.





A 204 T353 These services have been denied since they represent services which are not a covered benefit under Medicare and are not reimbursable under a SecureHorizons®/Oxford plan.


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A 204 T355 These services have been denied since they represent services which are not a covered benefit under Medicare and are not reimbursable under a SecureHorizons?/Oxford plan.


A 204 T376 These services have been denied since they represent services which are not a covered benefit under Medicare and are not reimbursable under a SecureHorizons®/Oxford plan




A 204 T385 Dental care including office care, diagnostic x-rays and surgical procedures is not a covered benefit under this plan.






9 204 T414 These services have been denied since they represent services which are not a covered benefit under Medicare and are not reimbursable under a SecureHorizons®/Oxford plan.

A 204 T415? These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.





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A 204 T553 This service has been denied because it is not a covered benefit under SecureHorizions(R)/Oxford plans. For additional information about the benefits please refer Members to their Evidence of Coverage or contact Customer Service at (800) 234-1228.


A 204 T572 This service has been denied because it is not a covered benefit under SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228.






A 204 T584 These services have been denied since they represent services which are not a covered benefit under Medicare and are not reimbursable under a SecureHorizons®/Oxford plan



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A 204 T627 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance




A 204 TBMC These services have been denied since they represent services which are not a covered benefit under Medicare and are not reimbursable under a SecureHorizons®/Oxford plan.

A 204 TCA2 This service has been denied because it is not a covered benefit under SecureHorizions(R)/Oxford plans. For additional information about the benefits please refer Members to their Evidence of Coverage or contact Customer Service at (800) 234-1228.

A 204 TCA3 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 204 TCA4 This service has been denied because it is not a covered benefit under SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228.

A 204 TCPT These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 204 TDBD This service has been denied because it is not a covered benefit under SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228.

A 204 TIP1 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A 204 TJHC This service has been denied because it is not a covered benefit under SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228.

A 204 TNCV These charges have been denied since they represent services which are not covered under the Member's plan. Please refer to the Member's Certificate of Coverage or Summary Plan Description for more information.

A 204 TNMC These services have been denied since they represent services which are not a covered benefit under Medicare and are not reimbursable under a SecureHorizons®/Oxford plan.

A 204 TPDC Dental care including office care, diagnostic x-rays and surgical procedures is not a covered benefit under this plan.


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A 204 TVNC This service has been denied because it is not a covered benefit under SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228.

A 204 TWG2 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

A A1 D21B EOB is PAYMENT FOR SERVICES PROHIBITED BY MEDICARE LAWS. BALANCE BILLING IS PROHIBITED.

A A1 D50 This claim has been denied due to a lack of funding by your employer. Your employer provides health care coverage on a self-insured basis with Oxford serving as a third party administrator. Under this arrangement, your employer is responsible for providing funds to Oxford to cover all claims costs before Oxford can issue payment. Please check with your benefits department if you have additional questions regarding your health coverage.

A A1 D58 These services are not eligible for reimbursement since they are considered to be covered under the Pre-Paid Partnership arrangement.

A A1 D60 Claim Denied Per Special Investigations Unit. A A1 D60F According to Oxford eligibility requirements, this group was not eligible for

coverage at time of enrollment. A A1 T407 These services have been denied since they represent services which are

not a covered benefit under Medicare and are not reimbursable under a SecureHorizons®/Oxford plan.

A A2 A10 This claim has been adjusted and Oxford's payment now reflects the correct HMO DRG rate for this admission. Oxford's payment is considered payment in full and the Member is not responsible for any additional payment, beyond the applicable coinsurance/deductible.

A A2 A17 Stop Payment Confirmed A A2 A17 Stop Payment Confirmed A A2 A24 The DRG rate reimbursed on this claim has been adjusted based on an

audit review. If you have any questions, please contact Oxford's Provider Services Department.

A A2 A26A The payment for these services is consistent with the employer's determination of the plan benefits.

A A2 A500 The Member's $500 co-payment has been waived, because he/she was readmitted to the hospital with the same diagnosis within 90 days of his/her hospitalization. The claim has been adjusted accordingly.

A A2 A51 This claim has been paid in full by Oxford in accordance with our contracted rates for consulting specialists. The Member is not responsible for any additional copayment byeond the applicable coinsurance/deductible requirements.

A A2 A53 Oxford's payment on this claim represents payment based on the Medicare DRG rate.

A A2 A57 Paid Lesser Medicaid paid billed charges A A2 A60 This claim has been reimbursement at the Assistant Surgeons which is

16% of the Medicare Maximum allowable fee. A A2 A65 This claim was paid according to the applicable Medicare outpatient rate, in

accordance with CMS guidelines.


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A A2 A75 This payment reflects the applicable monthly Medicare rate for the skilled nursing facility service(s) the Member received.

A A2 A8 This claim was paid per Oxford's Medical Management Department A A2 A8D The service you rendered was reviewed by an Oxford Medical Consultant

and the claim was paid accordingly. A A2 A8H The service you rendered was reviewed by a Home Care provider and the

claim was paid accordingly. A A2 A8J This radiology service is reimbursed as authorized by CareCore national

(without contrast). Providers are to notify CareCore national within 48 hours of rendering services to request an update to an existing authorization.

A A2 A8P PROVIDER PROJECT REVIEW A A2 A90W Oxford's payment on this service represents payment as the secondary

carrier. The allowed amount represents billed charges. The claim was repriced.

A A2 AOF1 This service, performed in this setting, qualifies for the office facility allowance. The allowable amount has been increased by a flat fee assigned to Level 1.

A A2 AOF2 This service, performed in this setting, qualifies for the office facility allowance. The allowable amount has been increased by a flat fee assigned to Level 2.

A A2 D19F This code is part of the Curascript contract and is paid to Curascript only. This code is not payable to a Curascript network provider.

A A2 NE4 MEDICAL MGMT APPEAL OVERTURNED A A2 NE9 ADJUSTMENT MADE THROUGH GRIEVANCE PROCESS. A A2 OC1 A stop payment has been issued on the check originally issued for this

claim. Oxford will complete the processing of a new check shortly. A A2 RC1 Original check returned to Oxford Health Plans. A A2 RF1 LOCKBOX REFUND - COLLECTIONS ISSUE A A2 RF19 Arbor Healthcare refund received and applied to claims. A A2 RF2 OMNI refund received and applied to claims. A A2 RF4 AIM REFUND - COLLECTIONS ISSUE A A2 RF5 COLLECTIONS ISSUE - FORGED ENDORSEMENT A A2 RF6 Refund received from the Rawlings Company. A A2 RF7 Refund received from Sagebrush Solutions A A2 RF8 Medical Recovery Management refund received and applied to claims. A A2 RF9 Collections Offset A A2 T360 The services denied require clinical review. In order for us to reconsider

payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A A2 T361 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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A A2 T471 These services require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review medical documentation for each date that the Member received care from you, starting from when the member began care for this episode. Medical documentation includes: (1) office notes, SOAP (subjective, objective, assessment, plan/procedure) notes with exam narratives, or equivalent notes which show the Member's condition and progress, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the level of service billed matches the service provided. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45 days, to: TRIAD Healthcare, Inc., P.O. Box 905, Plainville, CT 06062-0905. (Please note that federal law requires you to supply the Member with medical notes upon the Member's request.) If notes have been sent directly to TRIAD, you do not need to resubmit them in response to this request and will receive a written decision within 30 days from TRIAD's receipt of the notes. If you would like to confirm that TRIAD has received the notes, please call TRIAD at 800-409-9081.

A A2 T472 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e. office notes) to substantiate the services provided. Please send this documentation to: Triad Healthcare, Inc., P.O. Box 905, Plainville, CT 06062-0905



A A2 T505 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

A A2 TPED An adjustment has been made to this claim to reflect an updated usual, customary and reasonable allowance for this procedure.

A B1 D2E These services were formally denied because they were not authorized in advance with OrthoNet.

A B1 D2F Participating providers must authorize chiropractic services in advance of providing such services. These services were denied because they were not authorized in advance. Participating providers have 48 hours after rendering care to request an update to an existing authorization

A B1 TCT4 These services have been denied since they were not authorized in advance by the Member's Primary Care Physician. All specialty services including diagnostic laboratory testing, radiological testing and specialist consultations must be authorized in advance by the Member's Primary Care Physician to be eligible for coverage under SecureHorizons(R)/Oxford plans.

A B11 A58A This claim was adjudicated by Health Partners.


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A B11 A5H Heritage Adjustment. This claim reflects an adjustment. The original claim was processed by Heritage Medical Group.

A B11 A5M Claim paid per member Chiropractic Benefit A B11 D20B This claim is being sent to ACN Group, our chiropractic delegate, for

processing. Future chiropractic claim(s) must be submitted to : ACN Group, P.O. Box 5600 Kingston, NY 12402-5600

A B11 D20C This claim is being sent to ACN Group, our chiropractic delegate for processing. Any chiropractic claims with DOS after 2/29/08 must be submitted to ACN Group, P O Box 30982 Salt Lake City, UT 84130

A B11 D48 SUBMIT YOUR CLAIM TO BROOKLYN HEALTH PARTNERS FOR PAYMENT AT: BROOKLYN HEALTH PARTNERS 40 RICHARDS AVENUE 6TH FLOOR NORWALK, CT 06854

A B11 D48A This claim was denied by Health Partners A B11 D49 The prescription(s) submitted have been forwarded to Oxford's Pharmacy

Department for processing. A B11 D54A Your claim was sent to Oxford's contracted mental health provider for

processing. A B11 D65 Oxford has received your claim. However, your dental claims are processed

by our dental claims processing unit in Schenectady, NY We have forwarded your claim to them. Please send all dental claims directly to OXHP Health Insurance Company, Inc. Post Office Box 224. Schenecta, NY 12301 or call us at (888) 846-DENT.

A B11 D65A Oxford has received your dental claim. However your dental claims are processed by our dental claims processing unit in Eatontown, NJ. We have forwarded your claim to them. In the future, please send all dental claims directly to: Oxford Health Plans, Dental Administrative Office, PO Box 609, Eatontown, NJ 07724-0609.

A B11 D83E Member is a part of Cathedral Health Care group health plan. This benefit is self funded by Cathedral Health Care and therefore Oxford Health Plans is not responsible for payment.

A B11 D83U Services prior to Oxford enrollment, sent to prior carrier UHG for processing.

A B13 A105 Payment was rendered prior to Oxford's receipt of a hospital claim. If, after the claim is received, it is determined that the hospital is financially responsible for any portion of this claim, we will bill them accordingly.

A B15 D91 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 D91A In order to reimburse for moderate sedation, the related surgical code must be on file. At this time, we have not received a claim with the related surgical code. Upon receipt of the claim with the surgical code, this claim will be reviewed for reimbursement determination.

A B15 T332 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.



A B15 T443 This service has been denied because there is a mismatch between the diagnosis and procedure.


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A B15 T506 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.






A B15 TAHC This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TBON This service is not eligible for reimbursement as a separate procedure as it is considered part of a more global procedure that was performed and is therefore considered inclusive. Please do not balance bill the member.

A B15 TCH3 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TCON This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TCS5 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TCS6 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TDPS This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 THC1 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TIV1 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TNCS This procedure cannot be reimbursed as a stand alone procedure. Member cannot be balance billed

A B15 TPCV This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TQC2 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TRA1 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B15 TRA2 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

A B16 TNEW Initial visit allowed once every three yrears. Please resubmit with correct code.

A B18 D11E This code has been replaced


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A B18 D13C This claim contains coding which has been discontinued of labeled as invalid in accordance with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines. Please resubmit this claim with the appropriate diagnosis, procedure, Place and modifier codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027.

A B18 D13M Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062

A B18 DE2 Oxford Health Plans is a United Healthcare subsidiary. This service has been denied in accordance with your agreement and the member is not responsible for any payment on this service.

A B18 DE5 Oxford Health Plans is a United Healthcare subsidiary. This claim contains coding which has been discontinued or labeled as invalid in accordance with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines. Please resubmit this claim with the procedure codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027.

A B18 T07D Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062

A B18 T417 This Claim Contains A Procedure Code Or Codes Which Have Been Discontinued. Please Refer To The Current Version Of Your Cpt Coding Manual For More Information. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A B18 T589 Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062




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A B18 TBCR Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropri

A B18 TBRC Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropri

A B18 TD07 This service has been denied because it was not submitted with an appropriate CPT code. Please resubmit this claim with an appropriate code and/or include the clinical information necessary to describe the billed services.

A B18 TDEL This Claim Contains A Procedure Code Or Codes Which Have Been Discontinued. Please Refer To The Current Version Of Your Cpt Coding Manual For More Information. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A B18 TIDX This claim contains coding which has been discontinued or labeled as invalid in accordance with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines. Please resubmit this claim with the appropriate diagnosis, procedure, place and modifier codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, CT 06601-7027.

A B18 TMN1 This service has been denied because it was not submitted with an appropriate CPT code. Please resubmit this claim with an appropriate code and/or include the clinical information necessary to describe the billed services.

A B18 TMN2 Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropri

A B18 TMOD This claim contains coding which has been discontinued or labeled as invalid in accordance with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines. Please ask your Provider to resubmit this claim with the appropriate diagnosis, procedure and modifier codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027.

A B18 TOB2 This service has been denied because it was not submitted with an appropriate CPT code. Please resubmit this claim with an appropriate code and/or include the clinical information necessary to describe the billed services.

A B18 TOFC This code has been replaced. A B18 TULC Oxford Health Plans is unable to process this service because the billed

medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062

A B22 A16 This claim has been adjusted because we received a diagnosis code for the services performed


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A B22 A84 This claim payment reflects a biologically-based diagnosis for this service. A B22 TNJP This claim payment reflects a biologically-based diagnosis for this service. A B22 TNYP This claim payment reflects a biologically-based diagnosis for this service. A B5 A26 This claim is being paid on an exception basis. Future claims for these

services will not be covered under this plan if the correct procedures are not followed. Please refer to your Provider Reference Manual for more information.

A B5 D13S Initial visit allowed once every three years. Please resubmit with correct code.

A B7 A2 This claim has been adjusted and now reflects the provider's correct name and identification number.

A B7 D19A Primary Care Physicians are not eligible to receive reimbursement for services usually performed by Consulting Specialists in the Oxford network of providers. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to a secondary insurance carrier that the patient may have.

A B7 D19D This claim has been denied as the services billed are not included in the providers negotiated contract with Oxford.

A B7 D19E This procedure has been denied because the provider is not privileged to perform this service.

A B7 D60B Provider did not have a license on this date of service A B7 D60H Charges cannot be considered because we are unable to verify an active

license. Please submit proof of licensure within 45 days. A B7 T478 These services have been denied since the provider has been deemed to

be ineligible to perform these services under the terms of your plan. A B7 THOL This procedure has been denied because the provider is not privileged to

perform this service. A D21 TMOD This claim contains coding which has been discontinued or labeled as

invalid in accordance with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines. Please ask your Provider to resubmit this claim with the appropriate diagnosis, procedure and modifier codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027.

R M119 D13Q Oxford is unable to provide payment at this time based on the information that has been submitted. Please resubmit your claim with the product name, followed by a valid National Drug Code (NDC) number along with the strenght and quantity of the drug that was provided on the date of service billed.

R M123 D13Q Oxford is unable to provide payment at this time based on the information that has been submitted. Please resubmit your claim with the produc t name, followed by a valid national drug code (ndc) number along with the strength and quantity of the drug that was provided on the date of service billed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M125 T533 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R M127 D13V Send entire Medical Records to: Oxford Health Plans, Inc. Attention: Debora Scanlon P.O. Box 7078 Bridgeport Connecticut 06601


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R M127 D13W Cosmetic services are not covered. If you feel the service was medically necessary, please resubmit the claim with medical records or other supporting data, and Oxford Health Plans will re-review. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45-days, to: Oxford Health Plans, Inc., Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027 (Please note that federal law requires the provider to supply a patient with medical notes if requested.)

R M127 T352 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration.

R M127 TNYC Cosmetic services are not covered. If you feel the service was medically necessary, please resubmit the claim with medical records or other supporting data, and Oxford Health Plans will re-review. You or your provider should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45-days, to: Oxford Health Plans, Inc., Attn: Corrected/Resubmitted Claims, P.O. Box 7017, Bridgeport, CT 06601-7017 (Please note that federal law requires your provider to supply you with medical notes upon your request.)

R M135 D2I An IFSP from the municipality is needed to determine medical necessity. Mail IFSP to Oxford Health Plans, Early Intervention Program, Attn: Clinical Appeals, P.O. Box 7078, Bridgeport, CT 06601.

R M141 D35 Pre-certification is required after the 15th visit for chiropractic services rendered through 12/31/99. The provider needs to call 1-888-454-0620 to request authorization for the services rendered beyond the 15th visit

R M141 D35C Payment of this claim has been denied due to lack of medical necessity. R M143 D13L Oxford Health Plans is unable to process this claim because the servicing

provider lacks the state licensing information in their Oxford Health account. In order for Oxford Health Plans to abide by state compliance regulations, your provider must submit a new claim, along with their Behavioral Health Registration Certificate, to the following address: Oxford Health Plans, Provider Operations Dept., 10 Tara Blvd., Nashua, NH 03062, Attention: Provider Operations

R M16 D1 These charges have been denied since they represent services which are not covered under your plan. Please refer to your certificate of coverage or contact Oxford's Member Services Department for further assistance.

R M16 D36 Oxford considers reimbursement of the ambulance attendant(s), supplies and the first 30 miles one way, reflected in the fee paid for in the ambulance service.

R M23 A18A If additional reimbursement is warranted, please resubmit with corresponding invoice

R M25 D13A CPT code billed is not substantiated by the medical documentation submitted.

R M25 TGNF CPT code billed is not substantiated by the medical documentation submitted.

R M25 TGNM CPT code billed is not substantiated by the medical documentation submitted.


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R M29 T526 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M29 T598 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R M29 TBD The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M29 TBD3 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.







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R M29 TBD9 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M29 TBDA The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M29 TBDC The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R M29 TBDX The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R M29 TBDY The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R M29 TBDZ The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R M29 TINJ The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M33 D13J This claim could not be processed as the Federal Tax ID # (FTIN) for the provider is missing. Please provide the FTIN and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M51 TUNL Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062

R M53 A109 The claim you submitted appears to indicate dosage in lieu of units in the units field. Due to the various methods that this drug is dispensed, we cannot determine if the units billed are appropriate. If you disagree with units that were paid on this claim, please resubmit this claim with the corresponding NDC number to: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, CT 06601-7027.

R M53 AP28 For processing purposes, this service line has been recoded with a single unit


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R M54 D13H This claim could not be processed as the amount billed is missing from the claim. Please supply a billed amount and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M56 D13K This claim could not be processed as the Federal Tax ID# (FTIN) submitted with this claim is incorrect. Please provide the correct FTIN and resubmit the claim. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M62 D6 These services have been denied since we have no record of being notified of emergency services are unable to determine the nature of services performed. Emergent care is defined as treatment, which if not immediately received, could result in the physical impairment or death of a member. Additionally, Oxford must be notified within 48 hours of an emergency treatment. If you have further questions please contact Member Services.

R M64 T321 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.






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R M64 TDX1 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M64 TDX2 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M67 A23 This claim has been adjusted and now reflects the correct date(s) of service.

R M67 D11E This code has been replaced R M67 D13C This claim contains coding which has been discontinued of labeled as

invalid in accordance with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines. Please resubmit this claim with the appropriate diagnosis, procedure, Place and modifier codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027.

R M67 D13F This claim could not be processed as CPT codes were missing. Please provide the appropriate CPT codes and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M67 D13R The Procedure code billed can be classified as a bilateral procedure. Therefore, if procedure was performed bilaterally, please re-bill with appropriate units and/or modifier. If not performed bilaterally, please submit with appropriate medical documentation to substantiate. Thank you

R M67 TBIL The procedure code billed can be classified as a bilateral procedure. Therefore, if procedure was performed bilaterally, please re-bill with appropriate units and/or modifier. If not performed bilaterally, please submit with appropriate medical documentation to substantiate. Thank you

R M67 TDU1 This claim could not be processed as CPT codes were missing. Please provide the appropriate CPT codes and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M67 TIDX This claim contains coding which has been discontinued or labeled as invalid in accordance with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines. Please resubmit this claim with the appropriate diagnosis, procedure, place and modifier codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, CT 06601-7027.

R M67 TMOD This claim contains coding which has been discontinued or labeled as invalid in accordance with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines. Please ask your Provider to resubmit this claim with the appropriate diagnosis, procedure and modifier codes to Oxford Health Plans, Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027.


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R M81 D16 No diagnosis was provided with your claim. Please obtain a diagnosis from your healthcare provider and resubmit this claim. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M81 D16A Oxford is unable to process this claim since a medical diagnosis was not reported for this service. Oxford will only consider claims submitted with a corresponding medical diagnosis code. Please resubmit this claim with the appropriate medical diagnosis code(s) to Oxford and mark the new submission "corrected bill". Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M85 A8 This claim was paid per Oxford's Medical Management Department R M85 A8A This claim was paid per clinical review R M85 A8B The service you rendered was reviewed by an Oxford Clinical Resource

Specialist and the claim was paid accordingly. R M85 A8C The service you rendered was reviewed by an Oxford Medical Director and

the claim was paid accordingly. R M85 A8D The service you rendered was reviewed by an Oxford Medical Consultant

and the claim was paid accordingly. R M85 A8H The service you rendered was reviewed by a Home Care provider and the

claim was paid accordingly. R M85 A8P PROVIDER PROJECT REVIEW R M85 D1K These services have been denied per review by our dental consultant. R M86 T316 This code cannot be accepted twice. R M97 D14 This service has already been reimbursed as a part of the fee paid to the

hospital for hospital based services. R M97 T558 This service has already been reimbursed as a part of the fee paid to the

hospital for hospital based services. R MA01 D46 This service has been denied because it is not a covered benefit under

SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228

R MA01 T414 These services have been denied since they represent services which are not a covered benefit under Medicare and are not reimbursable under a SecureHorizons®/Oxford plan.




R MA01 T611 This service has been denied because it is not a covered benefit under SecureHorizions(R)/Oxford plans. For additional information about the benefits please refer Members to their Evidence of Coverage or contact Customer Service at (800) 234-1228.


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R MA01 TPNC This service has been denied because it is not a covered benefit under SecureHorizons(R)/Oxford plans. For additional information about their benefits, Members should refer to their Evidence of Coverage or contact Customer Service at (800) 234-1228.

R MA01 TROM This service has been denied because it is not a covered benefit under the Oxford Medicare Advantage Plan. For additional information about Oxford's Medicare benefits, members should refer to their Evidence of Coverage or contact Medicare Customer Service at (800) 234-1228.

R MA09 D33 We are unable to process this claim as the assignment of benefit information provided is not consistent on the claim form.

R MA105 D13P The CPT code does not correspond with the place of service as billed. Please resubmit the correct place or CPT code. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R MA105 T509 The CPT code does not correspond with the place of service as billed. Please resubmit the correct place or CPT code.

R MA113 A44 This claim has been paid to the patient because we are not in receipt of Form W-9, request for taxpayer identification number and certification. Please forward a copy via facsimile to (203) 851-2750, Attention: Finance Department

R MA118 D51 Veteran Administration Medical Center (VAMC) services are covered under the Veteran's benefit policy. Services from VAMC's were denied for this reason. Please forward claim to the VAMC for processing purposes.

R MA13 A46A Oxford paid this claim at the Medicare limiting charge amount as you are not a participating provider with Oxford's Medicare program and you do not accept Medicare assignment. The limiting charge amount is payment in full. The Member is not responsible for any additional payment, beyond applicable costshare.

R MA13 D21B EOB is PAYMENT FOR SERVICES PROHIBITED BY MEDICARE LAWS. BALANCE BILLING IS PROHIBITED.

R MA130 D20 Oxford has denied this claim due to missing information. Additional information concerning this claim was requested more than 30 days ago and has not been received. Please call Member Services for further clarification.

R MA30 D34 This claim could not be processed with the bill provider. Please resubmit this claim information on a UB92 form.

R MA31 D13G Thisclaim could not be processed as the date of service(s) is missing. Please resubmit the claim with date of service information. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R MA31 TDU2 Thisclaim could not be processed as the date of service(s) is missing. Please resubmit the claim with date of service information. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R MA36 D13D This claim could not be processed as the patient's name is missing or unclear. Please resubmit clearly indicating the patient's name. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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R MA47 D21E Medicare Opt Out Provider: Payment for services prohibited by Medicare law. Balance billing is allowed.

R MA61 D13E Patient's Oxford ID number is missing, please supply patient's Oxford ID number

R MA61 D31 We are unable to process these charges with the bill forwarded with this claim. Oxford requires an itemized bill for services which indicates the provider's name, address, tax identification number, patient's name, patient's Oxford number, date(s) of service, CPT code(s), medical diagnosis and billed charges. Please resubmit your claim with an itemized bill including all of the above information. If this claim was submitted to Oxford in error, please send to the correct insurance carrier.

R MA67 A14 This code, when submitted twice, justifies the replacement shown. R MA67 A15 This claim has been adjusted to correct the assignment of benefits

indicated on the claim form. R MA67 A17 Stop Payment Confirmed R MA67 A25 This claim has been adjusted to correct the assignment of benefits.

Payment is now being issued to the subscriber. R MA67 A38 This claim has been adjusted based upon our receipt of documentation

confirming full-time student status of this Member. R MA74 A15 This claim has been adjusted to correct the assignment of benefits

indicated on the claim form. R MA74 A17 Stop Payment Confirmed R MA74 A95 Partial refund received and applied to claims. R MA74 A95 Partial refund received and applied. R MA74 D95 Partial refund received and applied. R MA74 D95 Refund received and applied to claims. R MA74 OC1 A stop payment has been issued on the check originally issued for this

claim. Oxford will complete the processing of a new check shortly. R MA74 RC1 Original check returned to Oxford Health Plans. R MA74 RF1 LOCKBOX REFUND - COLLECTIONS ISSUE R MA74 RF19 Arbor Healthcare refund received and applied to claims. R MA74 RF2 OMNI refund received and applied to claims. R MA74 RF20 Arbor Healthcare refund received and applied to claims. R MA74 RF3 OMNI refund received and applied to claims. R MA74 RF4 AIM REFUND - COLLECTIONS ISSUE R MA74 RF5 COLLECTIONS ISSUE - FORGED ENDORSEMENT R MA74 RF6 Refund received from the Rawlings Company. R MA74 RF7 Refund received from Sagebrush Solutions R MA74 RF8 Medical Recovery Management refund received and applied to claims. R MA74 RF9 Collections Offset R MA91 A5A Oxford has received the appeal to this claim, and it has been accepted. R MA91 NE4 MEDICAL MGMT APPEAL OVERTURNED R MA91 NE9 ADJUSTMENT MADE THROUGH GRIEVANCE PROCESS. R N10 A37G Reviewed Medical Notes, DRG adjusted R N10 A8L Claim submitted for inpatient services has been reimbursed per the DRG

determined to be appropriate based on Oxford’s Clinical Claims Review Unit’s review of medical notes.

R N102 D38A This claim has been denied as the requested medical information has not been provided.


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R N109 D38 The service was denied after review by an Oxford Medical Director. A separate letter was sent explaining the basis for the denial. If you would like to appeal the Medical Director's determination, you must follow the appeal rights provided in the separate determination letter and submit an appeal within 180-days from receipt of that letter. If you have any other questions or appeals concerning the processing of this claim, please follow the claims review process shown on the last page of this Explanation of Benefits.

R N109 D38F The billed service was denied after review by an Oxford Chiropractic Clinical Reviewer. A separate letter was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180 days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business Member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60 days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance Advice.

R N111 D4 This claim has been denied as it represents a duplicate submission of a claim previously processed by Oxford. Please check your records for this statement.

R N111 D4B This claim has been denied as it represents a duplicate submission of a claim previously processed by Oxford. Please check your records for this statement.

R N111 T100 This claim has been denied as it represents a duplicate submission of a claim previously processed by Oxford. Please check your records for this statement.


R N111 T101 This claim has been denied as it represents a duplicate submission of a claim previously processed by Oxford. Please check your records for this state ment.







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R N118 D11B This service code is only billable 1 time within a 30 day time frame from the previous date of service it was billed per the American Medical Association Guidelines.

R N118 T533 This service code is only billable 1 time within a 30 day time frame from the previous date of service it was billed per the American Medical Association Guidelines.

R N123 DP47 This service line submitted with multiple units will be recoded to multiple service lines to separate the units

R N129 D1P This service/claim is denied in accordance with the maximum age limit per state mandate for coverage for infertility benefits.

R N129 TCTA This service/claim is denied in accordance with the maximum age limit per state mandate for coverage for infertility benefits.

R N129 TNJA This service/claim is denied in accordance with the maximum age limit per state mandate for coverage for infertility benefits.

R N129 TNJI This service/claim is denied in accordance with the maximum age limit per state mandate for coverage for infertility benefits.

R N130 T444 These services have been denied since they exceed the maximum benefit provided under your plan. Please refer to your certificate of coverage or contact member Services if you have any further questions.

R N163 D60L Charges cannot be considered because services billed are not documented as performed.

R N174 D27 The laboratory services performed have been denied because they were not performed by an Oxford Laboratory Network Provider. As an Oxford participating provider, all diagnostic laboratory testing should be forwarded to an Oxford Laboratory Network Provider. Any laboratory testing performed in your office is not eligible for reimbursement and cannot be billed to the member.

R N174 T455 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.


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R N174 TCS1 Primary Care Physicians are not eligible to receive reimbursement for services usually performed by Consulting Specialists in the Oxford network of providers. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to a secondary insurance carrier that the patient may have.

R N179 D17 This claims has been denied since we have not receive documentation of this Member's student status for this date of service. Oxford required documentation of full time dependent student status from the Registrar's office of an accredited educational institution at the beginning of the Fall and Spring semesters. Please forward a letter from he Registrar's office indicating full-time student status with this Explanation of Benefits to the Issue Resolutions Department for reconsideration.

R N179 D20E This claim was denied due to missing enrollment information which has been requested from the member or the member’s employer and was not received prior to processing of this claim.

R N179 D42 Our records reflect that another insurance carrier may be the primary insurer for these services. To date, we have not received a response to the Coordination of Benefits (COB) questionnaire recently forwarded to the Member for completion. All outstanding claims will be reviewed upon receipt of the questionaire from the member.

R N18 A51 This claim has been paid in full by Oxford in accordance with our contracted rates for consulting specialists. The Member is not responsible for any additional copayment byeond the applicable coinsurance/deductible requirements.

R N18 A53 Oxford's payment on this claim represents payment based on the Medicare DRG rate.

R N18 A60 This claim has been reimbursement at the Assistant Surgeons which is 16% of the Medicare Maximum allowable fee.

R N18 A62 Referred by a participating provider. All non-participating providers providing medical services to SecureHorizons?/Oxford members are reimbursed at the applicable Medicare rate.

R N18 A65 This claim was paid according to the applicable Medicare outpatient rate, in accordance with CMS guidelines.

R N18 A68 This claim has been adjusted to reflect Medicare reimbursement standards for claims with multiple surgical procedures. The primary procedure has been paid at 100% of the Medicare rate (according to CMS guidelines); and additional procedures have been paid at 50% of the Medicare rate.

R N18 A70 This claim has been adjusted to reflect Medicare reimbursement standards for two surgical procedures. The primary procedure has been paid at 100% of the Medicare rate (according to CMS guidelines); and the secondary procedure has been paid at 50% of the Medicare rate.

R N18 A75 This payment reflects the applicable monthly Medicare rate for the skilled nursing facility service(s) the Member received.

R N18 A90Y Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Medicare’s allowed amount. The claim was repriced.

R N18 D52 This service is covered under the Member's Federal Medicare card and is considered exempt from coverage by SecureHorizons®/Oxford plans. This claims should be filed with Federal Medicare.


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R N185 D83 This claim has been denied because it was either billed in error, the charges have been canceled or the services were not actually performed. This information was received directly fromthe provider.

R N189 A5C Under temporary procedures to expedite claims payment, Oxford has issued payment on claims which are typically denied or paid at a reduced rate. All future claims will be subject to contracted rates, according to standard remibursement procedures.

R N189 A5D Under temporary procedures to expedite claims payment, Oxford has issued payment on claims which are typically denied or paid at a reduced rate. All future claims will be subject to contracted rates, according to standard remibursement procedures.

R N189 A86 This claim has been adjusted and is being reimbursed on an exception basis. Generally, the services described are excluded under this contract and this payment does not ensure reimbursement for future occurences.

R N189 NE3 ADMINISTRATIVE EXCEPTION R N19 D11 This service is not eligible for reimbursement as a separate procedure as it


R N19 D11A Oxford's reimbursement for office services includes performing this procedure and thus it is not payable as a separate item.

R N19 D11C In accordance with generally accepted medical coding guidelines, this procedure is considered a component of the major surgical procedure performed and is not reimbursable as a separate item. This service is only considered a covered benefit though the primary surgical allowance.

R N19 D11T This service is not eligible for reimbursement as a separate procedure as it is considered part of the URN Global Case Rate and is therefore considered inclusive. The member is only responsible for the applicable copay, deductible or coinsurance

R N19 D11U This service is not eligible for reimbursement as a separate procedure as it is considered part of the URN Global Case Rate and is therefore considered inclusive. The member is only responsible for the applicable copay, deductible or coinsurance.

R N19 D5 Allergy serum covered with Office Visit R N19 T331 This service is not eligible for reimbursement as a separate procedure as it


R N19 T334 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

A N19 T335 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive. Please do not balance bill the member.


R N19 T335 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive. Please do not balance bill the member.


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R N19 T345 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive. Please do not balance bill the member.






R N19 T460 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.










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R N19 TBND This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

R N19 TCH4 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

R N19 TCOD This service is ineligible for reimbursement as a separate procedure under Oxford policy, which is based upon Medicare's Correct Coding initiative (CCI). According to CCI, this procedure may not be billed with the other procedure(s) performed and is not

R N19 TCPS This service is ineligible for reimbursement as a separate procedure under Oxford policy, which is based upon the Current Procedural Terminology (CPT) guidelines and other general industry guidelines. According to these guidelines, this service is considered part of the comprehensive procedure that was performed and is not payable separately. Participating providers may not balance bill the member for this service.


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R N19 TDSG This service is ineligible for reimbursement as a separate procedure under Oxford policy, which is based upon the Current Procedural Terminology (CPT) guidelines and other general industry guidelines. According to these guidelines, this evaluation and management service is considered a component of the major surgical procedure performed and is not reimbursable as a separate item. Reimbursement for this service is included in the reimbursement for the comprehensive surgical procedure that was performed. Participating providers may not balance bill the member for this service.

R N19 TGO1 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

R N19 TGSP This service is ineligible for reimbursement as a separate item under Oxford policy, which is based upon Medicare's Correct Coding initiative (CCI) and other general industry guidelines. This service is considered a component of the major surgical procedure performed and is not reimbursable as a separate item. Reimbursement for this service is included in the reimbursement for the comprehensive surgical procedure that was performed. Participating providers may not balance bill the member for this service.

R N19 TLB1 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

R N19 TLB2 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

R N19 TMC1 This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

R N19 TNTI This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

R N19 TOB2 Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062

R N19 TPAR This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed.

R N19 TREC This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

R N19 TSSV This service is not eligible for reimbursement as a separate procedure as it is considered part of the more global procedure that was performed and is therefore considered inclusive.

R N192 D45 This claim has been denied since the services performed are not covered under Medicaid and is not reimbursable under the Healthy Start Program. If you should have any questions, please refer to your MMIS Provider Manual or contact Member Services at 800 444-2413 for assistance.


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R N208 A37D To appeal DRG, please send medical notes to: Oxford Health Plans Inc. Attention: Debora Scanlon P.O. Box 7078 Bridgeport, CT 06611

R N208 A37G Reviewed Medical Notes, DRG adjusted R N219 A11Z Oxford's payment on this service represents payment as the secondary

carrier. The allowed amount represents Oxford's allowed amount. R N219 A27 Oxford's payment on this service represents payment as the secondary

carrier. The allowed amount represents Medicare's allowed amount. Participating Providers may not balance bill Members for Covered Services in excess of the applicable co-pay, co-insurance, or deductible.

R N219 A27Z Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents Medicare's allowed amount.

R N22 A13 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 A13A This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 T300 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.









R N22 T522 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide


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R N22 TAN2 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 TAN3 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 TBEN This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 TBL3 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 TCS2 This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 TNPT This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 TRAN This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N22 TVIS This claim has been adjusted to reflect the correct procedure codes in accordance with guidelines set forth in the American Medical Association's Current Procedural Terminology (CPT) guide.

R N225 D107 We had previously requested additional information that is necessary to process your claim. The information submitted does not comply with that request; therefore, your claim has been denied. Participating provider may not balance bill the member for this service.


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R N25 D50 This claim has been denied due to a lack of funding by your employer. Your employer provides health care coverage on a self-insured basis with Oxford serving as a third party administrator. Under this arrangement, your employer is responsible for providing funds to Oxford to cover all claims costs before Oxford can issue payment. Please check with your benefits department if you have additional questions regarding your health coverage.

R N256 D13I This claim could not be processed as the name and address of the provider is missing from the claim. Please provide the name and address of the provider and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N258 D13I This claim could not be processed as the name and address of the provider is missing from the claim. Please provide the name and address of the provider and resubmit. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N26 D29 We need an itemized bill reflecting services rendered to the patient to complete the processing of this claim. Please re-submit this claim with an itemized bill which includes the date of service, procedure code(s) relating to the services performed, medical diagnosis, and corresponding charges.

R N26 D30 We are unable to process these charges with the bill forwarded with this claim. Oxford requires an itemized bill of services which indicates the provider's name, address and tax identification number, the patient's name and identification number, the date(s) of service, CPT code(s), medical diagnosis and billed charges. Please resubmit your claim with an itemized bill including all pertinent billing information.

R N286 D20A Oxford is unable to process this claim due to missing information. Oxford requires that all non-participating lab claims include the referring provider’s NPI or UPIN. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 A18 Our records indicate a comprehensive visit has taken place within the past 6 months, therefore Oxford has recoded the claim line. Additional documentation is required to substantiate medical necessity for future visits.

R N29 A18B Oxford realizes there are times when additional reimbursement is warranted based on the complexity of the procedure. Oxford will allow additional reimbursement for modifiers -22 and -63 based on clinical review of the medical records/reports. Please submit medical documentation (i.e. office notes, operative reports) to substantiate the services billed.

R N29 D13 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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R N29 D13B The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 D13U These services require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review the operative report for this surgical procedure and any supporting clinical information showing why an assistant surgeon was required. We will use this information to evaluate whether or not the assistant surgeon services were medically necessary. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45-days, to: Oxford Health Plans, Inc., Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027 (Please note that federal law requires the provider to supply a patient with medical notes if requested.)

R N29 D13X The Member’s health benefits plan requires an authorization be obtained in advance of receiving this service. Medical necessity review is required for this study, which will include a review of your credentials. We need to review medical documentation related to the study (office notes, operative reports, results of available studies/tests, and any other relevant documentation) and information about your facility qualifications to render these services. Information about your qualifications must address the following: 1. Does your facility currently have a 64 slice CT scanner on site? If Yes, please note the Manufacturer 2. Does your facility have a lab director/Cardiac Imaging Specialist (CIS) that has performed 100 exams and interpreted 200 additional exams? If Yes, please list the CIS name. 3. Will a physician be on site for the performance of all CCTA exams? You or the Member must return a copy of this Remittance Advice Statement, and the requested information within 45 days to Corrected/Resubmitted Claims, Oxford Health Plans, P.O. Box 7027, Bridgeport, CT 06601-7027. Although you do not participate with Oxford, if your facility meets our designation requirements for this study, you may become credentialed and avoid the qualification review portion of future medical necessity reviews. You may obtain our detailed designation criteria and the Professional Physician/Practice Assessment (PPPA) form at www.carecorecardiology.com. We will review completed PPPA forms sent to: Credentialing Department CareCore National 169 Myers Corners Road Wappingers Falls, NY 12590


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R N29 D13Z The services denied require clinical review by the Dental Department. In order for us to reconsider payment, please return this EOB with dental documentation (i.e., treatment record notes/operative report, diagnostic test results, imaging (CT/MRI) reports, comprehensive TMJ evaluation) to substantiate the services provided. Do not submit radiographs (digital or standard film) at this time, if needed, radiographs will be requested at the time of review by the Dental Department. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 D1M This claim has been denied because 50 signatures were not obtained as required according to the benefit

R N29 D35A This claim has been denied as office notes are needed for review. R N29 D35B This claim has been denied as there is no care plan on file. A care plan is

needed after the 8th visit. R N29 D35E These services require clinical review. Benefits are only available for

covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review medical documentation from this visit. Medical documentation includes: (1) office notes that detail the members condition and progress, specifically range of motion measurements, strength measurements, functional deficits, and pain level, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the service billed matches the service provided. You should return a copy of this Remittance Advice, along with the medical documentation related to these services, within 45 days, to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 D35F These services require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review medical documentation for each date that the Member received care from you, starting from when the member began care for this episode. Medical documentation includes: (1) office notes, SOAP (subjective, objective, assessment, plan/procedure) notes with exam narratives, or equivalent notes which show the Member's condition and progress, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the level of service billed matches the service provided. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45 days, to: TRIAD Healthcare, Inc., P.O. Box 905, Plainville, CT 06062-0905. (Please note that federal law requires you to supply the Member with medical notes upon the Member's request.) If notes have been sent directly to TRIAD, you do not need to resubmit them in response to this request and will receive a written decision within 30 days from TRIAD's receipt of the notes. If you would like to confirm that TRIAD has received the notes, please call TRIAD at 800-409-9081.


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R N29 D38C The operative report and other medical documentation previously requested have not been received. As set forth in the Member’s health benefits plan, this information was required to be submitted within 45-days of the notice. We advised you of this timeframe on the prior Remittance Advice for this service and the Member was advised on his/her Explanation of Benefits. Since the requested information was not received, the claim is denied because without the information, medical necessity of the services cannot be established. A separate letter was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180-days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business Member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60-days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance Advice.

R N29 D38G Medical necessity has not been demonstrated. In order for Oxford to consider payment, please return this Explanantion of Benefits with medical documentation (i.e. care plans / office notes) to substantiate the services rendered.

R N29 D60A Services billed were unable to be substantiated. For reconsideration of this claim, please submit requested records to Oxford Health Plans, P.O. Box 315 Monroe, CT 06468 within 5 business days.

R N29 D60E Oxford has requested information from member/provider in order to consider this claim for payment. That information has not been received at this time. Please submit requested records to Oxford Plans, PO Box 315, Monroe, CT 06468 with in 45 days.

R N29 D60G Please submit the complete medical record (including but not limited to, initial patient intake form, history, physicals, progress notes, consultation letters, lab/radiology/pathology reports). Submit requested information, including claim form, to PO Box 315, Monroe, CT 06468 within 45 days.

R N29 D60M Further investigation of billed service required; please submit supporting documentation to validate coding. Please submit medical records to Mail Route MN002-0265, 12125 Technology Drive, Eden Prarie, MN 55344.

R N29 D60N Further investigation of billed service required; please submit supporting documentation to validate coding. Please submit medical records to PO Box 315 Monroe CT, 06468 Deactivated code as of 3/15/2008

R N29 T13B The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 T326 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027,


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Bridgeport, CT 06601-7027.

R N29 T397 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


R N29 T470 Medical necessity has not been demonstrated. In order for Oxford to consider payment, please return this Remittance Advice with medical documentation (i.e., office notes) to substantiate the services provided.

R N29 T471 These services require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review medical documentation for each date that the Member received care from you, starting from when the member began care for this episode. Medical documentation includes: (1) office notes, SOAP (subjective, objective, assessment, plan/procedure) notes with exam narratives, or equivalent notes which show the Member's condition and progress, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the level of service billed matches the service provided. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45 days, to: TRIAD Healthcare, Inc., P.O. Box 905, Plainville, CT 06062-0905. (Please note that federal law requires you to supply the Member with medical notes upon the Member's request.) If notes have been sent directly to TRIAD, you do not need to resubmit them in response to this request and will receive a written decision within 30 days from TRIAD's receipt of the notes. If you would like to confirm that TRIAD has received the notes, please call TRIAD at 800-409-9081.

R N29 T472 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e. office notes) to substantiate the services provided. Please send this documentation to: Triad Healthcare, Inc., P.O. Box 905, Plainville, CT 06062-0905



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R N29 T482 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 T506 This procedure cannot be reimbursed as a stand-alone procedure. Member cannot be balance billed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.







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R N29 TBEH Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 TD13 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 TDU3 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N29 TFM3 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed.

R N29 TFM4 Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which supports the service performed.

R N29 TPSY Oxford is unable to process this claim due to missing information. Oxford requires that all claims include an itemized bill of services rendered, medical diagnosis code(s), CPT code(s), place of service and any other pertinent clinical information which s

R N30 D60C According to Oxford eligibility requirements, individual was not eligible for coverage at time of enrollment.

R N31 D60B Provider did not have a license on this date of service R N32 D13N Oxford is unable to pay for these services because the servicing provider is

not listed on the submitted claim. To abide by CMS regulations, it is required that a claim contain no defect or impropriety which prevents timely payment. Please submit a new "clean" claim to the address below. Oxford Health Plans, PO Box 7082, Bridgeport, CT 06601-7082

R N329 A12 This claim has been adjusted and now reflects the patient's correct date of birth.


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R N34 D67 This claim cannot be processed with the bill provided. Please resubmit the claim on an Inpatient billing form (UB92).

R N35 D60 Claim Denied Per Special Investigations Unit. R N360 D9 Our records reflect that another insurance carrier is the primary insurer for

this service. Please submit these charges to the primary carrier for processing. Once a settlement has been reached, please submit an itemized bill of services rendered along with the primary insurer's explanation of benefits (EOB) to: Oxford Health Plans, Attn: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, CT 06601-7027.

R N383 D13W Cosmetic services are not covered. If you feel the service was medically necessary, please resubmit the claim with medical records or other supporting data, and Oxford Health Plans will re-review. You should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45-days, to: Oxford Health Plans, Inc., Attn: Corrected/Resubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027 (Please note that federal law requires the provider to supply a patient with medical notes if requested.)

R N383 D1E The removal of skin tags is considered a cosmetic procedure and is not a covered benefit under this plan.

R N383 D1F The services indicated on this claim have been determined to be cosmetic in nature and are not covered under this plan. Cosmetic procedures are performed to alter the natural appearance of the individual and not to treat a specific medical condition.

R N383 D1J The treatment of alopicea (hair loss) is considered a cosmetic procedure and is not a covered benefit under this plan.

R N383 TBC2 The services indicated on this claim have been determined to be cosmetic in nature and are not covered under this plan. Cosmetic procedures are performed to alter the natural appearance of the individual and not to treat a specific medical condition.

R N383 TNYC Cosmetic services are not covered. If you feel the service was medically necessary, please resubmit the claim with medical records or other supporting data, and Oxford Health Plans will re-review. You or your provider should return a copy of this Explanation of Benefits, along with the medical documentation related to these services, within 45-days, to: Oxford Health Plans, Inc., Attn: Corrected/Resubmitted Claims, P.O. Box 7017, Bridgeport, CT 06601-7017 (Please note that federal law requires your provider to supply you with medical notes upon your request.)

R N4 D15 Our records reflect that the explanation of benefits provided from the primary carrier is incomplete. Please refer to the additional comments provided below for an explanation of the missing information. Please submit a copy of this statement along with the missing information to: Oxford Health Plans, Attn: Corrected/Resubmitted Claims, PO Box 7027, Bridgeport, C 06601-7027. Please contact Oxford's Customer Service department for any further assistance.

R N424 D1N Oxford does not coordinate payment on claims totaling less than $50.00 for NJ small and individual plans.

R N45 A22 This claim was billed as an HMO claim. However, payment has been issued based on the commercial rate coinciding with this Member's indemnity insurance coverage.


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R N45 A24 The DRG rate reimbursed on this claim has been adjusted based on an audit review. If you have any questions, please contact Oxford's Provider Services Department.

R N45 A26 This claim is being paid on an exception basis. Future claims for these services will not be covered under this plan if the correct procedures are not followed. Please refer to your Provider Reference Manual for more information.

R N45 A26A The payment for these services is consistent with the employer's determination of the plan benefits.

R N45 A34 This claim has been paid as an HMO benefit on an exception basis since the Member was referred to this non-participating provider by an Oxford Participating Provider. Future visits to non-participating providers will not be covered as an HMO benefit unless authorized in advance by Oxford.

R N45 A57 Paid Lesser Medicaid paid billed charges R N45 A8J This radiology service is reimbursed as authorized by CareCore national

(without contrast). Providers are to notify CareCore national within 48 hours of rendering services to request an update to an existing authorization.

R N45 A90W Oxford's payment on this service represents payment as the secondary carrier. The allowed amount represents billed charges. The claim was repriced.

R N45 AOF1 This service, performed in this setting, qualifies for the office facility allowance. The allowable amount has been increased by a flat fee assigned to Level 1.

R N45 AOF2 This service, performed in this setting, qualifies for the office facility allowance. The allowable amount has been increased by a flat fee assigned to Level 2.

R N54 A100 This inpatient claim was incorrectly authorized as an outpatient service. Oxford is paying the claim as billed, however future payments may be reduced or denied if Oxford is not notified of a change in service setting before the service is rendered.

R N54 D35H The services have been reimbursed as authorized by CareCore National. Services related to contrast material were not authorized. If you believe the services billed were medically appropriate, you must submit medical notes demonstrating that the level of service billed was medically appropriate. The medical notes along with this EOB should be sent to CareCore National (address) within 45 days of this notification for additional information.

R N56 D11E This code has been replaced. R N56 T417 This Claim Contains A Procedure Code Or Codes Which Have Been

Discontinued. Please Refer To The Current Version Of Your Cpt Coding Manual For More Information. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N56 TDEL This Claim Contains A Procedure Code Or Codes Which Have Been Discontinued. Please Refer To The Current Version Of Your Cpt Coding Manual For More Information. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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R N59 RCRS Member is active with CRS (Cancer Resource Services). Please re-submit this claim directly to CRS for pricing. If you have any questions regarding this claim, please contact our Provider Services Department.




R N66 T502 Oxford Health Plans is unable to process this service because the billed medical codes are not consistent with the current American Medical Association Procedural Terminology. Please have your servicing provider submit a corrected claim, with the appropriate CPT medical codes, to the following address: Oxford Health Plans, Provider Operations Dept.,10 Tara Blvd., Nashua, NH 03062


R N66 T598 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R N66 TADM The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N66 TBD The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.


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R N66 TBD3 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.






R N66 TBD9 This service has been denied because there is a mismatch between the diagnosis and the procedure. Please submit this explanation of benefits with any medical records, which support the medical necessity of this service to Oxford Health Plans for reconsideration. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N66 TBDA The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N66 TBDC The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.


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R N66 TBDX The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R N66 TBDY The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R N66 TBDZ The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided.

R N66 TINJ The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N66 TMF3 The services denied require clinical review. In order for us to reconsider payment, please return this EOB with medical documentation (i.e., office notes, operative reports) to substantiate the services provided. Please resubmit the requested information for this claim to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R N77 A2 This claim has been adjusted and now reflects the provider's correct name and identification number.

R N90 D21D CMS prohibits payment directly to the Physician Assistant. To be proc essed, the claim must be submitted by the Supervising Physician.

R N95 A19B Effective 10/1/07, provider mut meet requirements in Cardiac CT screening policy at www.oxhp.com.

R N95 D19 These services have been denied since the provider has been deemed to be ineligible to perform these services under the terms of your plan.

R N95 D19A Primary Care Physicians are not eligible to receive reimbursement for services usually performed by Consulting Specialists in the Oxford network of providers. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to a secondary insurance carrier that the patient may have.

R N95 D19B This service has been denied since it represents services which fall outside the scope of the provider's license. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to any secondary insurance carrier that the patient may have.

R N95 D19D This claim has been denied as the services billed are not included in the providers negotiated contract with Oxford.

R N95 D19E This procedure has been denied because the provider is not privileged to perform this service.

R N95 D19F This code is part of the Curascript contract and is paid to Curascript only. This code is not payable to a Curascript network provider.

R N95 T322 These services have been denied since the provider has been deemed to be ineligible to perform these services under the terms of your plan.




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R N95 T395 This service has been denied since it represents services which fall outside the scope of the provider's license. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to any secondary insurance carrier that the patient may have.




R N95 T462 These services have been denied since the provider has been deemed to be ineligible to perform these services under the terms of your plan




R N95 T551 This procedure has been denied because the provider is not privileged to perform this service.




R N95 TAN1 These services have been denied since the provider has been deemed to be ineligible to perform these services under the terms of your plan.

R N95 TANM This service has been denied since it represents services which fall outside the scope of the provider's license. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to any secondary insurance carrier that the patient may have.

R N95 TBD1 This procedure has been denied because the provider is not privileged to perform this service.

R N95 TBD2 This procedure has been denied because the provider is not privileged to perform this service.

R N95 TBDB This procedure has been denied because the provider is not privileged to perform this service.

R N95 TOST This service has been denied since it represents services which fall outside the scope of the provider's license. As a participating provider, this expense may not be billed to the patient. You are free to bill this charge to any secondary insurance carri


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R A2 A500 The Member's $500 co-payment has been waived, because he/she was readmitted to the hospital with the same diagnosis within 90 days of his/her hospitalization. The claim has been adjusted accordingly.

A A5A Oxford has received the appeal to this claim, and it has been accepted. RF11 Rawling refund received and applied to claims. A 45 A37H This claim line has been adjustment to represent inpatient days that are

not supported due to lack of clinical information. This adjustment is for informational purposes only as the claim was paid at the appropriate DRG Contracted rate.

A 206 D20F We are unable to process this claim at this time due to a mssing or invalid NPI number which has ben mandated by CMS for submission. Please resubmit this claim with the requested information electronically or to corrected/Resubmitted claims, P.O. Box 702

A 45 A88N This claim has been paid in accordance with the member's benefit plan when using a non-network healthcare provider or facility

A 45 A79N This claim has been paid in accordance with the applicable out-of-network fee schedule for the services provided. Please contact Provider Services if you have any questions concerning the processing of this claim.

A 45 A88P this claim has been paid in accordance with the member's benefit plan when using a non network healthcare provider facility.

A 45 A79P This claim has been paid in accordance with the applicable out-of-network fee schedule for the services provided. Please contact Provider Services if you have any questions concerning the processing of this claim.

A 16 D13O We are unable to process this claim at this time due to a mssing or invalid Present on Admission Indicator which has been manadated by CMS for submission on inpatient claims. Please resubmit this claim with this information to Corrected/rResubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027 with the requested information to have this claim considered for payment.

R N434 D13O We are unable to process this claim at this time due to a mssing or invalid Present on Admission Indicator which has been manadated by CMS for submission on inpatient claims. Please resubmit this claim with this information to Corrected/rResubmitted Claims, P.O. Box 7027, Bridgeport, CT 06601-7027 with the requested information to have this claim considered for payment.

A 45 D7G The CMS Medicare standard limit for Oxygen rental is 36 continuous months, after which no additional reimbursement will be allowed on the rental.

R 119 D7G The CMS Medicare standard limit for Oxygen rental is 36 continuous months, after which no additional reimbursement will be allowed on the rental.

R M7 D7G The CMS Medicare standard limit for Oxygen rental is 36 continuous months, after which no additional reimbursement will be allowed on the rental.

A 45 A110 Additional amounts are being reimbursed as a result of an arbitrator's decision on your claim payment dispute.

R 64 A110 Additional amounts are being reimbursed as a result of an arbitrator's decision on your claim payment dispute.

A 197 D2P These services were formally denied because they were not authorized in advance with OptumHealth.


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A 16 D35P These services require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review medical documentation from this visit. Medical documentation includes: (1) office notes that detail the members condition and progress, specifically range of motion measurements, strength measurements, functional deficits, and pain level, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the service billed matches the service provided. You should return a copy of this Remittance Advice, along with the medical documentation related to these services, within 45 days, to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

R M62 D35P These services require clinical review. Benefits are only available for covered services that have been rendered and are determined to be medically necessary. For Oxford to consider payment, we need to review medical documentation from this visit. Medical documentation includes: (1) office notes that detail the members condition and progress, specifically range of motion measurements, strength measurements, functional deficits, and pain level, and (2) results of available x-rays or other imaging studies. We will use this information to evaluate medical necessity and to confirm that the service billed matches the service provided. You should return a copy of this Remittance Advice, along with the medical documentation related to these services, within 45 days, to: Corrected/Resubmitted Claims, Oxford Health Plans, PO Box 7027, Bridgeport, CT 06601-7027.

A 109 S7P Sent for OptumHealth PT/OT Review. A A1 D38Q The billed service was denied after review by a Clinical Reviewer. A separate letter

was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180 days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business Member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60 days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance Advice.

R N41 D38Q The billed service was denied after review by a Clinical Reviewer. A separate letter was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180 days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business Member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60 days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance Advice.

A A1 D38P The billed service was denied after review by a Clinical Reviewer. A separate letter was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180 days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business Member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60 days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance Advice.


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R N41 D38P The billed service was denied after review by a Clinical Reviewer. A separate letter was sent explaining the basis for the denial, which contains the appeal rights applicable to that determination. All appeals related to that determination must be submitted (1) within 180 days from receipt of the determination letter, or (2) if the decision was a retrospective utilization review determination for a New York line of business Member (as that term is defined under New York law and as described on the last page of this Remittance Advice), within 60 days from receipt of the determination letter. All other inquiries or appeals concerning the processing of this claim should be made consistent with the claim review process shown on the last page of this Remittance Advice.

Documents

HIPAA Adjustment and Remark Code Crosswalk