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Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
1 Liability Determination – Entire Claim Denied
The entire claim for injury has been denied; therefore, WSI is not
liable for payment of any charges relating to this injury. The
charge is the patient's responsibility. Please contact the patient
for payment or for other insurance information.
N Y
2Analyst Liability Determination – Unrelated
Service
This service is unrelated to the patient's work injury. The charge
for this service is the patient's responsibility. Please contact the
patient for payment or for other insurance information.
Y Y
3Liability Determination – No Further Liability
for Condition or no Medical Necessity
WSI previously determined that it has no liability or no medical
necessity for these charges. The charge is the patients’
responsibility. Please contact the patient for other insurance
information.
N Y
4 Third-Party Settlement – Suspended Benefits
Suspended benefits exist as part of a third-party settlement. The
amount approved shown is the patient's responsibility. The
patient cannot be billed for more than the amount approved as
shown in the approved column. Please contact the patient for
payment of the amount approved.
Y Y
5 Date of Service Error – Prior to Injury
This charge is denied because medical documentation indicates
this service was provided prior to the date of the patient's injury.
The charge is the patient’s responsibility. Please contact the
patient for the payment of the allowable amount.
N Y
6Medical Rule Exceeded – Nonreimburseable
Service – Not Billable to Patient
This charge is denied because WSI does not pay for this type of
service or procedure. The patient may not be billed for this
charge.
N Y
7 Funeral – Costs Exceed Maximum Allowed WSI's reimbursement of funeral expenses is exceeded. Y Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 1 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
9 * Duplicate Charge Submitted
This charge is denied as a duplicate charge. To request
reconsideration, complete the provider request for an adjustment
form (M6) and submit to WSI within 30 days from the date of the
remittance advice and provide a statement of why the reduction
or denial is disputed. You may also supply any supporting
documentation. The patient may not be billed for this reduced or
denied charge.
N Y
10 Claim Accepted on Aggravation
This claim has been accepted on an aggravation basis. The
charge is payable at the fee schedule allowable amount on an
aggravation percentage. Balance of the allowed charge is the
patient's responsibility. Please contact the patient for payment or
for other insurance information.
Y Y
11Liability Determination – Service Partially
Unrelated to Claim
This charge has been reduced by 50 percent of the fee schedule
because medical documentation shows services unrelated to the
patient's work injury were provided in addition to services related
to the patient's work injury. The balance of the charge is the
patient's responsibility. Please contact the patient for payment or
for other insurance information.
Y Y
12Audit Liability Determination – Unrelated
Service
This service is unrelated to the patient's work injury. The charge
is the patient's responsibility. Please contact the patient for
payment or for other insurance information.
Y Y
13 *Liability Determination – Requested Medical
Records Not Received
This charge is denied because the requested medical records
have not been received and WSI is unable to establish liability for
these charges. To request reconsideration, complete the
provider request for an adjustment form (M6) and submit to WSI
within 30 days from the date of the remittance advice and
provide the appropriate records along with a request for
reconsideration. The patient may not be billed for this charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 2 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
14Liability Determination – Unauthorized
Services – No Liability
This charge is denied because the services were not ordered by
the patient's attending doctor and WSI did not approve a change
of the attending doctor for this patient. The patient is responsible
for these charges. Please contact the patient for payment.
Y Y
17Legal Fees and Costs – Exceeded Maximum
Amount Payable
Your fees have been adjusted because the amount submitted
causes you to exceed the maximum amount payable.N Y
18 Legal Fees and Costs – Formal Hearing
Since the injured worker did not prevail at the formal hearing,
your fees and costs have been denied. If you disagree, contact
Legal Services, in writing, within 30 days from the date of the
remittance advice for reconsideration.
N Y
20 Miscellaneous – Zero Amount Submitted
Your charge for this service date was submitted as zero payable.
This notification is provided for your information. If this was billed
in error, please resubmit a corrected billing.
N Y
30 Internal Code – Do Not Deduct Overpayment Do Not Deduct Overpayment. N N
31Miscellaneous – Adjustment to Previous
ChargeAdjustment to Previous Charge. N Y
32Internal Code – Do Not Deduct Overpayment
and Do Not Apply AggravationDo Not Deduct Overpayment and Do Not Apply Aggravation. N N
34Audit Adjustment – Reversed – Original
Decision Overridden
The original recommendation relating to this charge has been
overridden. N Y
37Personal Reimbursement – No Receipts
Submitted
Your request for reimbursement is denied because you did not
provide itemized receipts. Please submit the original receipts if
you have them. If you disagree, you must file a request for
reconsideration, in writing, within 30 days from the date of the
remittance advice and provide appropriate record(s).
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 3 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
38Personal Reimbursement – Over One Year
Old
Your request for reimbursement is denied because it was not
filed within one year of incurred expense. If you disagree, you
must file a request for reconsideration, in writing, within 30 days
from the date of the remittance advice and provide a statement of
why the reduction or denial is disputed. You may also supply any
supporting documentation.
N Y
39Liability Determination – Stipulation – WSI
Pay Part or Zero - Patient to be Billed
This charge has been processed according to a settlement with
the patient. The charge is the patient's responsibility. Please
contact the patient for payment or for other insurance
information.
N Y
40Medical Rule Exceeded – Pharmacy – Over-
the-Counter Medication
This charge is denied because medical service rules limit
payment for over-the-counter medication. The charge is the
patient's responsibility. Please contact the patient for payment or
for other insurance information.
N Y
41 School Expenses – Allowance Exceeded
This charge is reduced or denied because the school supply
allowance has been exceeded for this school term. Please
contact the student for payment or for other insurance
information.
N Y
42 Legal Fees and Costs – Prior to EntitlementThese fees and costs are for services billed prior to the date you
are entitled to fees and costs. N Y
43Liability Determination – Stipulation – Fee
Schedule Applied.
This charge has been processed according to a settlement with
the patient. The patient may not be billed for this reduced or
denied charge.
N Y
44Liability Determination – Stipulation – Fee
Schedule Not Applied
This charge has been processed according to a settlement with
the patient.N Y
45Personal Reimbursement – Not Enough Miles
in a Month
Your request for reimbursement for mileage is denied because
you did not travel at least 200 miles during the calendar month. If
you disagree, you must file a request for reconsideration, in
writing, within 30 days from the date of the remittance advice
and provide a statement of why the reduction or denial is
disputed. You may also supply any supporting documentation.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 4 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
46Medical Rule Exceeded – Nonreimbursable
Service – Billable to Patient
This charge is denied because WSI does not pay for this type of
service or procedure. The charge is the patient's responsibility.
Please contact the patient for payment or for other insurance
information.
Y Y
47Personal Reimbursement – Vocational
Mileage
Reimbursement for mileage is denied because WSI does not
reimburse for mileage related to this vocational service. If you
disagree, you must file a request for reconsideration, in writing,
within 30 days from the date of the remittance advice and
provide a statement of why the reduction or denial is disputed.
You may also supply any supporting documentation.
N Y
49Manipulations Exceeded – 2 Chiro
Manipulations Per Day
This charge is denied because two or more chiropractic
manipulations per day are allowed only when provided within 72
hours of the original injury date. The patient may not be billed for
this charge.
N Y
51 *Service does not meet WSI’s practice or
treatment guidelines
This charge is denied because this service does not meet WSI’s
practice or treatment guidelines. To request reconsideration,
complete the provider request for an adjustment form (M6) and
submit to WSI within 30 days from the date of the remittance
advice and provide a statement of why the reduction or denial is
disputed. You may also supply any supporting documentation.
The patient may not be billed for this reduced or denied charge.
N Y
52 *
Services Not Provided – Medical
Documentation Doesn’t Support Submitted
Charge
This charge is denied as medical documentation does not
support the submitted charge. To request reconsideration,
complete the provider request for an adjustment form (M6) and
submit to WSI within 30 days from the date of the remittance
advice and provide a statement of why the reduction or denial is
disputed. You may also supply any supporting documentation.
The patient may not be billed for this reduced or denied charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 5 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
53 Chiropractic Modalities Limited to Two
This charge is denied because chiropractic modalities are limited
to two modalities per visit. The patient may not be billed for this
charge.
N Y
54 Fee Schedule Applied
This charge is reduced or denied as required by WSI's Medical
and Hospital Fee Schedule. The patient may not be billed for this
reduced or denied charge.
N Y
55Fee Schedule Not Applied – WSI Approved
Service
This charge has been paid in full because it was a service or
report requested or pre-approved by WSI.N Y
56 *Procedure Code Changed – Medical
Documentation Doesn't Support Code Used
This charge is reduced or denied because the medical
documentation does not support the submitted procedure code.
The procedure code has been changed. To request
reconsideration, complete the provider request for an adjustment
form (M6) and submit to WSI within 30 days from the date of the
remittance advice and provide a statement of why the reduction
or denial is disputed. You may also supply any supporting
documentation. The patient may not be billed for this reduced or
denied charge.
N Y
57 *Modifier Changed – Not Appropriate for
Procedure Performed
This charge is reduced or denied because the modifier submitted
is not appropriate for the procedure performed. The modifier was
changed. To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation. The patient may not
be billed for this reduced or denied charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 6 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
58 * UCR Exceeded – Service Charge
This charge is reduced or denied because it does not reflect the
usual, customary, or reasonable reimbursement level for this
service, To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation. The patient may not
be billed for this reduced or denied charge.
N Y
59 * Modifier 51 – Multiple Procedures Performed
This charge is reduced or denied because multiple procedures
were performed the same day or at the same session. Modifier
51 was added. To request reconsideration, complete the
provider request for an adjustment form (M6) and submit to WSI
within 30 days from the date of the remittance advice and
provide a statement of why the reduction or denial is disputed.
You may also supply any supporting documentation. The patient
may not be billed for this reduced or denied charge.
N Y
63UR Initial Rec – Service does not meet WSI’s
practice or treatment guidelines
This charge is denied because the initial utilization review
determined the service does not meet WSI’s practice or
treatment guidelines. Notice of decision denying service,
including information on your right to appeal, has been sent to
your facility. The patient may not be billed for this reduced or
denied charge.
N Y
69Internal Code – Pay in Full and Override
AggravationPay in Full and Override Aggravation. N N
70 Rehab – Late Report Penalty
This charge is reduced because a late report penalty has been
applied. To request reconsideration, contact WSI, in writing,
within 30 days. The injured worker may not be billed for the
balance of this reduced charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 7 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
71Rehab – Office / Clerical / Copy Charges
Denied
This charge is denied because WSI does not pay for office,
clerical, or copy charges. To request reconsideration, contact
WSI, in writing, within 30 days. The injured worker may not be
billed for this charge.
N Y
72 Rehab – Unauthorized Rehab Services
This charge is denied because the services performed were not
authorized by WSI. To request reconsideration, contact WSI, in
writing, within 30 days. The injured worker may not be billed for
this charge.
N Y
73 Rehab – Report Lacks Earning Capacity
This charge is reduced or denied because the submitted report
lacks information required by the contract. To request
reconsideration, contact WSI, in writing, within 30 days. The
injured worker may not be billed for this reduced or denied
charge.
N Y
74 Rehab – VCR Doesn't Meet Guidelines
This charge is reduced or denied because the submitted VCR
does not meet established WSI guidelines for an acceptable
report. To request reconsideration, contact WSI, in writing,
within 30 days. The injured worker may not be billed for this
reduced or denied charge.
N Y
75 Rehab – Unnecessary or Excessive Charges
This charge is reduced or denied because the service performed
was unnecessary or in excess of what was requested. To
request reconsideration, contact WSI, in writing, within 30 days.
The injured worker may not be billed for this reduced or denied
charge.
N Y
76 Rehab – Not Substantiated in Report
This charge is denied because the report is insufficient to support
payment for this service. To request reconsideration, contact
WSI, in writing, within 30 days. The injured worker may not be
billed for this charge.
N Y
77 Rehab – Exceeded Maximum Allowed
This charge exceeds the maximum allowed for the requested
service. To request reconsideration, contact WSI, in writing,
within 30 days. The injured worker may not be billed for this
charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 8 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
79UR Initial Rec – Insufficient Information
Received to Complete Review
This charge is denied because insufficient information was
received to complete an initial utilization review. Notice of
decision denying service, including information on your right to
appeal this decision, has been sent to your facility. The patient
may not be billed for this charge.
N Y
80 * UR Required – Service Not Pre-Certified
This charge is denied because the service was not reviewed
through utilization review. To request approval for a retrospective
review, complete the provider request for an adjustment form
(M6) and submit to WSI within 30 days. Please provide on the
form a statement of why it was not known that the injury may
have been a compensable injury. The patient may not be billed
for this charge.
N Y
81Personal Reimbursement – Wage Loss Not
Paid
Wage loss for attending medical examinations is paid only when
WSI has ordered the examination. If you disagree, you must file
a request for reconsideration, in writing, within 30 days from the
date of the remittance advice and provide a statement of why the
reduction or denial is disputed. You may also supply any
supporting documentation.
N Y
82 Personal Reimbursement – Meals Not Paid
Your request for this meal reimbursement is reduced or denied
because it exceeds the maximum allowed or is not reimbursable
within state guidelines. If you disagree, you must file a request for
reconsideration, in writing, within 30 days from the date of the
remittance advice and provide a statement of why the reduction
or denial is disputed. You may also supply any supporting
documentation.
N Y
83 Miscellaneous – Bill Sent in ErrorThis charge was submitted to WSI in error and is rejected per
your request.N Y
84Liability Determination – Requested Patient
Information Not Received
This charge is denied because information requested from the
patient has not been received. WSI is unable to establish liability
for these charges. The charge is the patient's responsibility.
Please contact the patient for payment or for other insurance
information.
Y Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 9 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
85UR Appeal Rec – Service does not meet
WSI’s practice or treatment guidelines
This charge is denied because utilization review appeal
determined the service does not meet WSI’s practice or
treatment guidelines. Notice of decision denying service,
including information on your right to appeal this decision, has
been sent to your facility. The patient may not be billed for this
reduced or denied charge.
N Y
88
UR Initial Rec Retro Review – Service does
not meet WSI’s practice or treatment
guidelines
This charge is denied because an initial retrospective review
determined the service or treatment does not meet WSI’s
practice or treatment guidelines. Notice of decision denying
service, including information on your right to appeal this
decision, has been sent to your facility. The patient may not be
billed for this reduced or denied charge.
N Y
90 *Audit – Treatment Exceeds Medical Rules and
Fee Guidelines
This charge is reduced or denied because medical
documentation indicates that treatment exceeds WSI’s Medical
Rules and Fee Guidelines. To request reconsideration, complete
the provider request for an adjustment form (M6) and submit to
WSI within 30 days from the date of the remittance advice and
provide a statement of why the reduction or denial is disputed.
You may also supply any supporting documentation. The patient
may not be billed for this reduced or denied charge.
N Y
91 *Medical Rule Exceeded – Service Not Pre-
Authorized by WSI
This charge is denied because the service, equipment, or
treatment was not pre-approved by WSI. To request
reconsideration, complete the provider request for an adjustment
form (M6) and submit to WSI within 30 days from the date of the
remittance advice. The patient may not be billed for this charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 10 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
93 *Medical Rule Exceeded – Equipment ,
Supplies, Hardware
This charge is reduced or denied because it exceeds the rule of
reimbursement for medical equipment, supplies, and hardware.
To request reconsideration, complete the provider request for an
adjustment form (M6) and submit to WSI within 30 days from the
date of the remittance advice and provide a statement of why the
reduction or denial is disputed. You may also supply any
supporting documentation. The patient may not be billed for this
reduced or denied charge.
N Y
94 *Medical Rule Exceeded – Medical Record
Copy Fee for Treatment Prior to Injury
This charge is reduced or denied because it exceeds WSI's rule
of reimbursement for medical records which allows five dollars for
five or fewer pages or five dollars for the first five pages plus
thirty-five cents per page for each page after the fifth. To request
reconsideration, complete the provider request for an adjustment
form (M6) and submit to WSI within 30 days from the date of the
remittance advice. The patient may not be billed for this reduced
or denied charge.
N Y
95 *Medical Rule Exceeded – Medical Record
Copy Fee for Current Treatment
This is not a reimbursable charge because the records requested
are for treatment WSI is covering for the injured employee. To
request reconsideration, complete the provider request for an
adjustment form (M6) and submit to WSI within 30 days from the
date of the remittance advice. The patient may not be billed for
this reduced or denied charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 11 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
98 *Modifier NP – Medical Documentation Shows
NP/PA Performed Service
This charge is reduced or denied because medical
documentation indicates this service was provided by a nurse
practitioner or physician’s assistant. Modifier NP has been
added. To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation. The patient may not
be billed for this reduced or denied charge.
N Y
99 *Modifier 80 – Medical Documentation Shows
Assistant Surgeon Service
This charge is reduced or denied because medical
documentation indicates a physician provided assistance to
another physician performing a surgical procedure. Modifier 80
has been added. To request reconsideration, complete the
provider request for an adjustment form (M6) and submit to WSI
within 30 days from the date of the remittance advice and
provide a statement of why the reduction or denial is disputed.
You may also supply any supporting documentation. The patient
may not be billed for this reduced or denied charge.
N Y
100 *Modifier SA – Medical Documentation Shows
Surgical Assistant Service
This charge is reduced or denied because medical
documentation indicates a non-physician assistant provided
assistance to a physician performing a surgical procedure.
Modifier SA has been added. To request reconsideration,
complete the provider request for an adjustment form (M6) and
submit to WSI within 30 days from the date of the remittance
advice and provide a statement of why the reduction or denial is
disputed. You may also supply any supporting documentation.
The patient may not be billed for this reduced or denied charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 12 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
102 * Modifier 50 – Bilateral Procedure Performed
This charge is reduced or denied because medical
documentation indicates bilateral procedures were performed.
Modifier 50 has been added. To request reconsideration,
complete the provider request for an adjustment form (M6) and
submit to WSI within 30 days from the date of the remittance
advice and provide a statement of why the reduction or denial is
disputed. You may also supply any supporting documentation.
The patient may not be billed for this reduced or denied charge.
N Y
104 *Modifier 26 – Medical Documentation Shows
Only Professional Component Done
This charge is reduced or denied because medical
documentation indicates this charge is for the professional
component only. Modifier 26 has been added. To request
reconsideration, complete the provider request for an adjustment
form (M6) and submit to WSI within 30 days from the date of the
remittance advice and provide a statement of why the reduction
or denial is disputed. You may also supply any supporting
documentation. The patient may not be billed for this reduced or
denied charge.
N Y
105 *Modifier TC – Medical Documentation Shows
Only Technical Component Done
This charge is reduced or denied because medical
documentation indicates this charge is for the technical
component only. Modifier TC has been added. To request
reconsideration, complete the provider request for an adjustment
form (M6) and submit to WSI within 30 days from the date of the
remittance advice and provide a statement of why the reduction
or denial is disputed. You may also supply any supporting
documentation. The patient may not be billed for this reduced or
denied charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 13 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
106 *Procedure Code Changed – Completed
Multiple Repair Same Classification
This charge is reduced or denied because medical
documentation indicates repair of multiple wounds of the same
classification was completed. The procedure code has been
changed. To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation. The patient may not
be billed for this reduced or denied charge.
N Y
115
UR Rec Ancillary Service – Primary Service
does not meet WSI’s practice or treatment
guidelines
This charge is denied because utilization review determined the
primary service does not meet WSI’s practice or treatment
guidelines. Notice of decision denying service, including
information on your right to appeal this decision, has been sent to
your facility. The patient may not be billed for this reduced or
denied charge.
N Y
116 Date of Service Error – Changed Date
The date of service has been changed as verification with your
facility indicates a different date of service than previously
submitted.
N Y
117 Tax – State Health Care Tax
The State Health Care Tax is not reimbursable as a separate
charge, but is considered included in your submitted charges for
the service performed. Submitted charges, including this tax, are
subject to the fee schedule allowable when ND has jurisdiction
over the work injury. The patient may not be billed for this tax.
N Y
118Tax – Exempt From North Dakota State Sales
Tax
WSI is a tax exempt agency pursuant to Subsection 6 of Section
57-39.2-04 of the North Dakota Century Code, certificate number
E-2001. No one may be billed for this tax.
N Y
119Medical Rule Exceeded – Eye Care – No
Change in Vision
This charge is denied because WSI does not reimburse eyewear
unless a change in sight attributable to the work injury has
occurred. This charge is the patient's responsibility. Please
contact the patient for payment or for other insurance
information.
Y Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 14 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
122 *Medical Rule Exceeded – Assistant Surgeon /
Surgical Assistant – Not Allowed
This charge is not reimbursable because the procedure code
does not support assistant surgeon / surgical assistant services.
To request reconsideration, complete the provider request for an
adjustment form (M6) and submit to WSI within 30 days from the
date of the remittance advice and provide a statement of why the
reduction or denial is disputed. You may also supply any
supporting documentation. The patient may not be billed for this
reduced or denied charge.
N Y
127Legal Fees and Costs – Exceeded Hourly
Rate
Your fees have been adjusted because the hourly rate submitted
on your statement exceeds the maximum allowable hourly rate.
To request reconsideration, contact Legal Services, in writing,
within 30 days.
N Y
130 *Units Changed – Medical Documentation
Doesn't Support Submitted Units
This charge is reduced or denied because medical
documentation does not support the number of units billed. The
number of units has been changed. To request reconsideration,
complete the provider request for an adjustment form (M6) and
submit to WSI within 30 days from the date of the remittance
advice and provide a statement of why the reduction or denial is
disputed. You may also supply any supporting documentation.
The patient may not be billed for this reduced or denied charge.
N Y
132Overpayment – Injured Worker Overpayment
Recovery
The approved amount of this charge has been applied to recover
an overpayment on your claim. Please contact your claims
analyst if you have questions about any overpayment on your
claim.
N Y
133Overpayment – Provider Overpayment
Recovery
The approved amount of this charge has been applied to recover
an overpayment to your facility. Please reference your prior
remittance advice statements for information on which claims
created the overpayment to your facility.
N Y
134 Legal Costs 3rd
Party – 50% Recovery WSI pays 50% of the costs of the action. N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 15 of 30
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Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
135Legal Costs 3
rd Party – Less Than 50%
Recovery
The costs of the action are prorated and adjusted on a
percentage of WSI's total subrogation interest recovered to the
total recovery in the action.
N Y
136 Personal Reimbursement – Motel Reduced
Your request for motel reimbursement is reduced because it
exceeds the maximum allowable reimbursement. If you disagree,
you must file a request for reconsideration, in writing, within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation.
N Y
137 Personal Reimbursement – Spouse Denied
Your request for reimbursement for expenses incurred by your
spouse or by another person who accompanied you to your
appointment is denied because there are no doctor's orders
indicating the need for accompaniment. Please submit a copy of
the Doctor’s Order which indicates that your medical condition
prevents you from traveling alone. If you disagree, you must file
a request for reconsideration, in writing, within 30 days from the
date of the remittance advice and provide appropriate record(s).
Y Y
138 Personal Reimbursement – Expenses Denied
Your request for reimbursement for expenses incurred due to
your appointment is denied because it was unnecessary for you
to seek medical treatment outside of your local area. If you
disagree, you must file a request for reconsideration, in writing,
within 30 days from the date of the remittance advice and
provide a statement of why the reduction or denial is disputed.
You may also supply any supporting documentation.
Y Y
139 Personal Reimbursement – Intracity Mileage
WSI does not reimburse for intracity mileage. If you disagree,
you must file a request for reconsideration, in writing, within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 16 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
140Personal Reimbursement – No Appointment
Verified
Your request for reimbursement for these expenses is denied
because WSI has no verification of an appointment on this date.
Please submit verification of the appointment. If you disagree,
you must file a request for reconsideration, in writing, within 30
days from the date of the remittance advice and provide
appropriate record(s).
N Y
141Legal Fees and Costs – Duplicate Charge
Submitted
This charge is reduced or denied because it is a duplicate
charge. The injured worker may not be billed for this charge. To
request reconsideration, contact Legal Services, in writing,
within 30 days.
N Y
142Legal Fees and Costs – Disallowed Under
NDCC
Payment of attorney fees and costs are not allowed under NDCC
Section 65-02-08. To request reconsideration, contact Legal
Services, in writing, within 30 days.
N Y
143Legal Fees and Costs – Negotiated Fee
Settlement
Contested attorney fees were reduced according to a negotiated
fee settlement.N Y
145 Internal Code – No Claim for Bill Entered This charge is not associated with any claim on file. N N
146 Audit – Split/Replace/Combine Line Item
This line item does not comply with billing methods required by
WSI and has been replaced with an appropriate line item. To
request reconsideration, complete the provider request for an
adjustment form (M6) and submit to WSI within 30 days from the
date of the remittance advice and provide a statement of why the
reduction or denial is disputed. You may also supply any
supporting documentation. The patient may not be billed for this
reduced or denied charge.
N Y
147 Personal Reimbursement – Mileage Reduced
Your request for mileage reimbursement is reduced because it
exceeds the miles actually and necessarily traveled. If you
disagree, you must file a request for reconsideration, in writing,
within 30 days from the date of the remittance advice and
provide a statement of why the reduction or denial is disputed.
You may also supply any supporting documentation.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 17 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
148Personal Reimbursement – Nonreimbursable
Expenses
Your request for personal reimbursement is reduced or denied as
these expenses are not reimbursable, have been previously
submitted, or exceeded the amount(s) allowed. . If you disagree,
you must file a request for reconsideration, in writing, within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation.
N Y
149Overpayment – Bill Paid to Wrong Payee /
Repaid to Correct Payee
This line item was paid to your facility in error and has created an
overpayment that must be recovered. This line is provided for
information only and is not included in calculating your total
remittance amount. The paid amount has been or will be
deducted from other payments owed to your facility. If no further
payments are owed to your facility, please send a check for the
total overpayment amount for deposit against the overpayment.
N Y
150Overpayment – Bill Paid to Correct Payee But
Paid in Error
This line item was paid incorrectly to your facility and has created
an overpayment that must be recovered. This line is provided for
information only and is not included in calculating your total
remittance amount. The paid amount has been or will be
deducted from other payments owed to your facility. If no further
payments are owed to your facility, please send a check for the
total overpayment amount for deposit against the overpayment.
N Y
151 Overpayment – Void Check
This line item reflects receipt of a returned check from your
facility. The check has been voided per your request. This line is
provided for information only and is not included in calculating
your total remittance amount. If necessary, you will be notified of
any additional payments through other remittance line item
transactions.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 18 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
152 Overpayment – Deposit Check
This line item reflects receipt of a deposit from your facility for an
overpayment. This line is provided for information only and is not
included in calculating your total remittance amount. If
necessary, you will be notified of any additional payments or
overpayments through other remittance line item transactions.
N Y
153Legal Fees and Costs – Reduced Pursuant to
NDCC
Attorney fees have been reduced to 20% of the awarded amount
pursuant to Sections 65-02-08 and 65-02-14, NDCC. If you
disagree, contact Legal Services, in writing, within 30 days for
reconsideration.
N Y
154 Legal Fees – 3rd PartyAttorney fees in connection with third-party actions are paid on a
percentage of the recovery pursuant to Section 65-01-09, NDCC.N Y
155 Personal Reimbursement – Motel Denied
Your request for motel reimbursement is denied because WSI
did not authorize this service. If you disagree, you must file a
request for reconsideration, in writing, within 30 days from the
date of the remittance advice and provide a statement of why the
reduction or denial is disputed. You may also supply any
supporting documentation.
N Y
158 Time Statements – Erroneously EnteredThis bill was erroneously entered into the system and should not
be paid.N N
159 Post – Rehab Manipulation
This charge is denied because the patient has completed the
Spinal Rehabilitation Program. The patient may not be billed for
these services.
N Y
160Closed Claim – No Further Liability for
Condition
This service is denied, as the claim is presumed closed. The
charge is the patient's responsibility. Please contact the patient
for payment or for other insurance information.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 19 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
161Overpayment – Injured Worker Advance
Payment
An advance payment was made to you. Upon completion of your
travel, you must submit a request for reimbursement on a C40a
form along with original receipts. If your actual expenses exceed
the amount of the advance, but do not exceed the maximum
allowable, additional reimbursement will be made to you. If you
do not submit a request for reimbursement, or if your actual
expenses are less than the advance, an overpayment will result.
If an overpayment does result, you will be notified by letter of the
amount you are required to reimburse WSI. If you disagree, you
must file a request for reconsideration, in writing, within 30 days
from the date of the remittance advice and provide a statement of
why the advance overpayment is disputed. You may also supply
any supporting documentation.
N Y
162No Liability for Palliative Chiropractic Care
Services
WSI previously determined that it has no liability for these
charges. The charge is the patient's responsibility. Notice of
decision denying service, including information on your right to
appeal this decision, has been sent to your facility. Please
contact the patient for payment or for other insurance
information.
Y Y
163Personal Reimbursement – Request for
Medical Services Denied
Your request for reimbursement for medical services is denied.
WSI requires all medical providers to submit billings directly to
WSI for payment of services directly related to workers'
compensation claims. Please contact your medical provider and
have them submit a bill to WSI directly. If we determine these
charges are our liability, payment will be made to the provider.
You may then seek reimbursement from the medical provider. If
you disagree, you must file a request for reconsideration, in
writing, within 30 days from the date of the remittance advice
and provide a statement of why the reduction or denial is
disputed. You may also supply any supporting documentation.
Y Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 20 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
164Miscellaneous – Injured Worker Returned
Item
Injured worker returned item and reimbursement should not be
provided for this service.N Y
165 Adjustment – Reversed – DecisionThe original recommendation relating to this charge has been
adjusted.N Y
166Adjustment – Reversed – Office of
Independent Review
The original recommendation relating to this charge has been
adjusted.N Y
167Adjustment – Reversed – Binding Dispute
Resolution
The original recommendation relating to this charge has been
adjusted.N Y
168 Adjustment – Reversed – LegalThe original recommendation relating to this charge has been
adjusted.N Y
169Legal Bill Auditing Guidelines Applied –
Administrative/Clerical
This billed line item is reduced or denied as being
clerical/administrative in nature and not payable in accordance
with Legal Services Management and Billing Guidelines for law
firms representing WSI.
N Y
170Legal Bill Auditing Guidelines Applied –
Internal Instructions
This charged line item is reduced or denied as it applies to
giving/receiving instructions for task accomplishment. Only the
fees of the senior party will be paid.
N Y
171Legal Bill Auditing Guidelines Applied –
Internal Conferences
This billed line item is reduced or denied, as WSI will only pay for
conferences, which are not administrative.N Y
172Legal Bill Auditing Guidelines Applied –
Photocopying
This photocopying expense is reduced or denied as excessive
without prior authorization or use of WSI facilities.N Y
173Legal Bill Auditing Guidelines Applied – Block
Billing
This charge is reduced or denied as block billing without
specifically identifying the time for each task within the block is
not payable.
N Y
174Legal Bill Auditing Guidelines Applied –
Overhead
Line item billing for items which are firm overhead and inclusive
within the hourly rate are reduced or denied.N Y
175Legal Bill Auditing Guidelines Applied –
Vagueness
Billing item is reduced or denied as it is vague and an accurate
determination of the services cannot be made.N Y
176Liability Determination – Injured Worker Failed
to See Designated Medical Provider
This charge is denied because the services were not provided by
the employer’s designated medical provider and the injured
worker has failed to select another medical provider prior to being
injured. The patient is responsible for these charges. Please
contact the patient for payment or other insurance information.
Y Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 21 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
177 Medical Records ReceivedThis charge has been reviewed again because requested
medical records have now been received.N Y
178 * Global Period Applied
This service is denied as included in global period to initial
procedure. To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation. The patient may not
be billed for this reduced or denied charge.
N Y
179 * Out-of-State Usual and Customary Applied
This charge is reduced or denied because it does not reflect the
usual, customary, or reasonable rate. To request
reconsideration, complete the provider request for an adjustment
form (M6) and submit to WSI within 30 days from the date of the
remittance advice and provide a statement of why the reduction
or denial is disputed. You may also supply any supporting
documentation. The patient may not be billed for this reduced or
denied charge.
N Y
181 * Medical Records Illegible
This charge is denied because medical records received were
illegible. To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide medical
notes in a typed format along with a request for reconsideration.
The patient may not be billed for this charge.
N Y
183 *Special Request – No Time for Service /
Procedure Submitted
This charge is reduced or denied because time spent on WSI’s
requested service / procedure was not noted in your review. To
request reconsideration, complete the provider request for an
adjustment form (M6) and submit to WSI within 30 days from the
date of the remittance advice The patient may not be billed for
this reduced or denied charge..
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 22 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
184Return-to-Work Case Management –
Unnecessary or Excessive Charges
This charge is reduced or denied because the service performed
was unnecessary or in excess of what was requested. To
request reconsideration, contact WSI, in writing, within 30 days.
The employee may not be billed for this reduced or denied
charge.
N Y
185Return-to-Work Case Management –
Unauthorized Disability Management Services
This charge is denied because the services performed were not
authorized by WSI. To request reconsideration, contact WSI, in
writing, within 30 days. The employee cannot be billed for this
charge.
N Y
186Liability Determination – Treatment Plan Not
Received
This charge is denied because no treatment plan has been
received. Per Administrative Rule 92-01-02-30 - Medical
services may be reimbursed only when provided according
to a written treatment plan. A copy of the treatment plan,
signed by the attending medical service provider, must be
provided to WSI within 14 days of beginning the treatment
or within 14 days of learning that the treatment is claimed to
be work related, whichever occurs later . To request
reconsideration, contact WSI, in writing, within 30 days, and
provide the written treatment plan along with a request for
reconsideration. The patient may not be billed for this charge.
N Y
187Return-to-Work Case Management –
Exceeded Maximum Allowed
This charge exceeds the maximum allowed for the requested
service. To request reconsideration, contact WSI, in writing,
within 30 days from the date of the remittance advice. The
employee may not be billed for this reduced or denied charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 23 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
188 * DRG Hospital Payment Formula Applied
This charge is reduced or denied as required by WSI’s Inpatient
Hospital Fee Schedule. To request reconsideration, complete the
provider request for an adjustment form (M6) and submit to WSI
within 30 days from the date of remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply any supporting documentation. The patient may not
be billed for this reduced or denied charge.
N Y
189 *DRG Outlier Hospital Payment Formula
Applied
This charge is reduced or denied as required by WSI’s Inpatient
Hospital Fee Schedule with an outlier threshold. To request
reconsideration, complete the provider request for an adjustment
form (M6) and submit to WSI within 30 days from the date of
remittance advice and provide a statement of why the reduction
or denial is disputed. You may also supply any supporting
documentation. The patient may not be billed for this reduced or
denied charge.
N Y
190Liaison Program – Documentation Does Not
Support the Charge
This charge is being denied because the documentation in the
claim file does not reflect a request for the assistance of the
liaison. The patient may not be billed for this charge.
N Y
191 Liaison Program – Duplicate ChargeThis charge has been paid on a previous invoice or is listed twice
on this invoice. The patient may not be billed for this charge.N Y
192Procedure Code Change – Service(s) Beyond
Compensable Work Injury
This code has been changed because medical documentation
shows service(s) beyond what is necessary to treat the
compensable injury were provided in addition to those related to
the work injury. The patient may not be billed for this charge.
Y Y
193 Miscalculated Transcription Fees
This charge has been reduced or increased because it does not
meet SIU’s rule of reimbursement for transcription, which allows
for three dollars and fifty cents ($3.50) per page.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 24 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
194 Unauthorized Expense
This charge has been reduced due to SIU being charged for an
expense which SIU does not cover, is exempt from, or SIU did
not authorize.
N Y
195Times Logged on Bill Do Not Coincide With
Times Logged on Report
This charge has been reduced or increased due to a “beginning
time” or an “ending time” on the bill not coinciding with the time
logged on your investigative report for that particular day.
N Y
196 Miscalculation of Travel Time
This charge has been reduced or increased due to a
miscalculation of the travel time. This change was due to one of
the following: 1) the “beginning time” to “ending time” did not
equal “total travel time” for a specific day; 2) the total travel time
for the bill was miscalculated; or, 3) the total travel time multiplied
by the approved rate paid by SIU was miscalculated.
N Y
197 Miscalculation of Sub-totalsThis charge has been reduced or increased due to a
miscalculation of the sub-totals to get the total amount of the bill.N Y
198 Miscalculation of Surveillance Time
This charge has been reduced or increased due to a
miscalculation of the surveillance time. This change was due to
one of the following: 1) the “beginning time” to “ending time” did
not equal “total surveillance time” for a specific day; 2) the total
surveillance time for the bill was miscalculated; or, 3) the total
surveillance time multiplied by the approved rate paid by SIU was
miscalculated.
N Y
199 Miscalculated Mileage
This charge has been reduced or increased due to a
miscalculation of the mileage. This change was due to one of the
following: 1) there was a miscalculation in miles for a given day;
2) there was a miscalculation in adding the “total miles” for the
bill; or 3) the total miles multiplied by the approved rate paid by
SIU was miscalculated.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 25 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
200 Claim Withdrawn
The entire claim for this injury has been withdrawn; therefore,
WSI is not liable for payment of any charges relating to this
injury. This charge is the patient’s responsibility. Please contact
the patient for payment or for other insurance information.
Y Y
201Medical Rule Exceeded – Charge Older than
One Year
This charge is denied because the bill was not submitted within
one year of the date of service or within one year of the date WSI
accepted liability for the work injury or condition. The patient may
not be billed for this charge.
N Y
202 Brand Medication Submitted
This charge is reduced because a generic brand must be
dispensed unless the ordering physician has stated “dispense as
written”. The patient is responsible for the difference between
the brand name and generic medication. Please contact the
patient for payment.
Y Y
203 Miscellaneous Addition to the Bill
This charge has been increased due to one of the following: 1)
meals for a given day were inadvertently left off the bill; 2) motel
charges were inadvertently left off the bill; or 3) another expense
was inadvertently left off the bill. Due to one of these changes,
the bill was recalculated and the total was changed.
N Y
204 * Audit Bill Type does not Qualify as Submitted.
This charge is denied as WSI has determined that the bill type
does not qualify as submitted. Please submit the corrected bill
type for services rendered. To request reconsideration, complete
the provider request for an adjustment form (M6) and submit to
WSI within 30 days from the date of the remittance advice and
provide a statement of why the reduction or denial is disputed.
You may also supply any supporting documentation. The patient
may not be billed for this reduced or denied charge.
N Y
205 Outpatient Packaged Services Denied
This charge is denied because WSI does not pay for this
packaged service, as required by WSI’s medical and hospital fee
schedule. The patient may not be billed for this charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 26 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
206 Home Modifications – Allowance Exceeded
This charge is reduced or denied because the home modification
allowance has been exceeded. The remaining balance is the
responsibility of the injured worker.
Y Y
207 Unauthorized Expense – RTW Services
This charge has been reduced due to RTW Services being
charged for an expense which RTW Services does not cover, is
exempt from, or RTW Services did not authorize.
N Y
209Personal Reimbursement - Request for
Pharmacy Denied
Your request for reimbursement for pharmacy is denied. WSI
requires all pharmacies to submit billings directly to the pharmacy
benefit management company, PBM. Please contact your
pharmacy and have them submit a bill to the PBM. If we
determine these charges are the responsibility of WSI, payment
will be made to the pharmacy. You may then seek
reimbursement from the pharmacy.
Y Y
210 WSI has opted out of the third party litigationWSI has opted out of the third party litigation pursuant to
N.D.C.C. § 65-01-09 and has no further liability for costs or fees.N Y
211 Internal code, ICD-9 adjustment ICD-9 adjustment N N
212 *Liability Determination – Medical records not
received
This charge is denied because the medical records have not
been received and WSI is unable to establish liability for these
charges. To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide the
appropriate records. The patient may not be billed for this
charge.
N Y
213 * W9 not received
This charge is denied because WSI has not received a W9
(Federal Taxpayer Identification Form). A W9 is necessary
before any payments can be made to your facility. To request
reconsideration, complete the provider request for an adjustment
form and submit to WSI within 30 days from the date of the
remittance advice. The patient may not be bill for this charge.
Y Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 27 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
215 * Anesthesia modifier missing
This charge is denied because the anesthesia modifier is
missing. To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide a
statement of why the denial is disputed. You may also supply
any supporting documentation. The patient may not be billed for
this reduced or denied charge.
N Y
216Preferred Worker unnecessary or excessive
reduction/denial
Preferred Worker, Unnecessary or Excessive Charges - This
charge is reduced/denied because the service or request was
unnecessary or not allowable.
N Y
217 Preferred Worker, Maximum reduction/denialExceeded Maximum Allowed -- This charge exceeds the
maximum allowed.N Y
218 * Audit - EMG
This charge is reduced or denied because electrodiagnostic
studies, may only be performed by electromyographers who are
certified or eligible for certification by the American Board of
Electrodiagnostic Medicine, American Board of Physical
Medicine and Rehabilitation, or the American Board of Neurology
and Psychiatry’s certification in the specialty of Clinical
Neurophysiology. To request reconsideration, complete the
provider request for an adjustment form (M6) and submit to WSI
within 30 days from the date of the remittance advice and
provide a statement of why the reduction or denial is disputed.
You may also supply supporting documentation. The patient
may not be bill for this reduced or denied charge.
N Y
219 *UR Required – Services/treatment not done in
a timely matter after approval.
This charge is denied because this service was not done within
authorization time frame. To request approval for a retrospective
review, complete the provider request for an adjustment form
(M6) and submit to WSI within 30 days.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 28 of 30
March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
220 *Billed time units – medical documentation
does not support submitted units.
This charge is reduced or denied because the total units billed for
the timed code does not match the documented total time
performed. To request reconsideration, complete the provider
request for an adjustment form (M6) and submit to WSI within 30
days from the date of the remittance advice and provide a
statement of why the reduction or denial is disputed. You may
also supply supporting documentation. The patient may not be
bill for this reduced or denied charge.
Y Y
221Pharmacy Reimbursement – submit pharmacy
bill to pharmacy benefit manager.
WSI requires all pharmacy or medication charges to be
submitted directly to the pharmacy benefit management
company, Tmesys (1-800-964.2531). The patient may not be
billed for this denied charge.
Y Y
222 * NCCI Edits, AMA and CPT edits
This charge is reduced or denied because of incorrect coding
combinations. WSI uses the National Correct Coding Initiative,
AMA and CPT edits. To request reconsideration, complete the
provider request for an adjustment form (M6) and submit to WSI
within 30 days from the date of the remittance advice. You may
also supply any supporting documentation. The patient may not
be billed for this reduced or denied charge.
N Y
223 Paradigm Management Services
This charge is denied because WSI has contracted with
Paradigm Management Services to manage, coordinate, and
reimburse for this catastrophic work injury. Please contact
Paradigm Management Services for reimbursement. Telephone
800.676.6777; Fax925.676.2197
N Y
224 * Invalid Code per WSI Guidelines
This charge is denied because the code submitted is invalid per
WSI coding guidelines. Resubmit the charge using the
appropriate code. If you disagree with the denial, you may
complete the provider request for adjustment form (M6) and
submit to WSI within 30 days from the date of the remittance
advice. You may also supply and supporting documentation.
The patient may not be billed for this reduced or denied charge.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
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March 2015
Remittance Advice Reason Codes
Reason Code Abbreviated Description Complete Description
Print Notice Non-
Payment to
Injured Worker
Print Line &
Code on
Payee Remit
225 Out of state claim filing
The charge is denied because the patient has filed in another
state and the claim is either pending or accepted in the other
state. Please contact the patient for payment or for other
insurance information.
Y Y
226Managed Care – Service Not Medically
Necessary
The charge is denied because it has been determined the service
is not necessary for treat or diagnoses of the compensable work
injury. Notice of decision denying/reducing service, including
information on your right to appeal, has been sent to your facility.
Please contact the patient for payment or for other insurance
information.
Y Y
227 Bunch CareSolutions Services
This charge is denied because WSI has contracted with Bunch
CareSolutions to reimburse medical bills for this injury. Please
submit charges to Bunch CareSolutions at Bunch CareSolutions
PO Box 32045, Lakeland, FL 33802 or call 888.853.4735 opt 6
Y Y
228 Medicare Processing
This charge has been processed according to WSI fee schedule.
The charges were initially paid in error by Medicare. WSI has not
accepted any additional liability past the charges paid. The
patient may not be billed for this reduced or denied charge.
N Y
229 Medicare Denial This charge was paid correctly by Medicare N Y
230 DRG - Primary Diagnosis Code not Submitted
This charge is denied because the principal diagnosis code is
missing. Please resubmit the corrected UB 04 for services
rendered with the required information. The patient may not be
billed for this denied charge.
N Y
231 Modifier 50 Incorrect Billing
This charge is denied because modifier 50 was used incorrectly
per WSI guidelines. Please review fee schedule requirements for
billing bilateral procedures on WSI website at
www.workforcesafety.com. Please resubmit the corrected bill for
services rendered. The patient may not be billed for this reduced
or denied charged.
N Y
* Effective January 1, 2015, pilot program lengthens the appeal timeframe
to 60 days from the date of the Remittance Advice for designated reason codes.
Page 30 of 30
March 2015