Understanding Claim Adjustment, Recoding, and Denial Reason
This reference guide is intended to help providers understand common claim adjudication outcomes and identify appropriate next steps when a service is denied, adjusted, recoded, or included in part of another reimbursable service.
The reason code descriptions below explain why a claim was processed in a particular manner and provide guidance on what to review before submitting a corrected claim, appeal, or provider inquiry.
Before Submitting an Inquiry
Many claim adjustments can be resolved by reviewing documentation, correcting coding, or submitting additional supporting information.
Please Review:
- The remittance advice and applicable reason code(s)
- Medical record documentation
- CPT®, HCPCS, and ICD-10 coding submitted on the claim
- Applicable coding guidelines and payment policies
- Member benefit coverage and eligibility
- Previously processed claims for the same member and date of service
- Medicare National Correct Coding Initiative (NCCI) Edits
DO NOT resubmit the original claim as a new claim. If your review identifies a billing, coding, modifier, diagnosis, or unit correction, submit a corrected claim with the appropriate updates.
For CMS-1500 claims: Resubmission of Claims (CMS-1500)
For UB-04 claims: Verifying Claims Status and Resubmission of Processed Claims (UB-04)
IF, after reviewing the claim determination and supporting documentation, you disagree with the outcome, you may submit a Provider Billing Dispute Appeal with supporting documentation for reconsideration. See Reference Document to submit an appeal.
The information provided in this guide is intended to help providers understand common claim adjudication outcomes. Coverage determinations, reimbursement methodologies, coding requirements, and benefit limitations are subject to applicable health plan policies, provider contracts, and industry-standard coding guidelines. This guide does not guarantee reimbursement and should not replace review of remittance advice, claim details, and supporting documentation.
Quick Reference Guide
The RTP message codes are provided as a reference and may be updated periodically. Based on the RTP message code identified on your Report to Provider (RTP), select the appropriate category below for additional guidance. If a specific RTP message code is not listed in this guide, please contact Provider Correspondence for further assistance and claim-specific guidance.
| Category | Report to Provider (RTP) Message Codes |
|---|---|
| B003, B007, B008AI, B011AI, B013AI, B023, B0183AI, B093AI, W003, W007, W008AI, W011AI, W013, W023, W093AI, W183AI | |
| B002, B009, B015, B016, B019AI, B049, B062, B063AI, B124, W002, W009, W015, W016, W019AI, W049, W056, W063AI, W124 | |
| B012AI, W012AI | |
| B006, B010, B014, W006, W010, W014 | |
| B004, B005, B017, B021, W004, W005, W017, W021 | |
| B020, W020 | |
| B034, B035AI, B036, B053AI, B056, B166AI, W034, W035AI, W036, W053AI, W056, W166AI |
Select options below for additional information
| Quick answers to common questions about claims reviews, reprocessing, and provider inquiries | |
| Submit an inquiry for claims believed to be processed incorrectly. HMSA will review and reprocess the claim if warranted. | |
| Related resources, forms, and contacts to help address claim questions and inquiries. |
Coding & Documentation Reviews
| Reason Code Description | What It Means | Provider Guidance |
|---|---|---|
| Procedure Code Changed Per Review | The submitted procedure code was reviewed and processed under a different procedure code. | Review the processed code and supporting documentation. |
| Procedure Inappropriately Coded | The submitted procedure code did not accurately represent the service performed. |
Review coding guidelines and medical record documentation to ensure the most appropriate code was submitted. |
| E/M Code Level Recoded | The submitted E/M level was adjusted based on coding and documentation review. |
Ensure documentation supports the level of service billed and review E/M coding guidelines |
|
The Diagnosis Codes On The Claim Do Not Support The Billed Procedure Code |
The submitted diagnosis code(s) does not support the billed procedure. |
Review diagnosis and procedure code combinations and submit a corrected claim if appropriate. |
| Incorrect Modifier |
The modifier billed is invalid, inappropriate, or not supported by the procedure reported. |
Review modifier requirements and submit a corrected claim if another modifier is appropriate. |
| Resubmit With Supporting Documentation | Additional documentation is required to adjudicate the claim. |
Submit a Provider Billing Dispute Appeal with supporting documentation for reconsideration. See Reference Document for additional information. |
| Recoded To A General Anesthesia Service Code | The submitted anesthesia service was reviewed and processed under a general anesthesia code. | Review anesthesia documentation and coding guidelines to verify whether the submitted code accurately reflected the service provided. |
Bundled & Inclusive Services
| Reason Code Description | What It Means | Provider Guidance |
|---|---|---|
| Included In Primary Procedure | The service is considered part of another reimbursable procedure and is not separately payable. | Review all services billed on the same date of service and applicable coding guidelines for bundled services. |
| Included In E/M Service |
The procedure is considered part of the E/M service and is not separately reimbursable. |
Review E/M documentation and determine whether separate reporting is supported by coding guidelines. |
| Mutually Exclusive Procedure |
Two procedures billed together are not typically performed during the same encounter. |
Review coding guidelines and documentation to determine whether separate reimbursement is supported. |
| Multiple Endoscopy Rules |
Reimbursement was adjusted based on multiple endoscopy payment guidelines. |
Review all endoscopy procedures billed on the same date of service and applicable reimbursement guidelines. |
|
The Add-On Code Was Denied Because The Primary Procedure Was Not Paid Or Was Not Identified On The Claim |
Add-on codes require an eligible primary procedure to be billed and reimbursed. | Verify that the appropriate primary procedure was billed and processed on the claim. |
Evaluation & Management (E/M) Services
| Reason Code Description | What It Means | Provider Guidance |
|---|---|---|
| Only One E/M Code Allowed Per Day | Multiple E/M services were billed when only one is allowed under policy. |
Review same-day E/M services and ensure documentation supports separate and distinct services when applicable. |
Global Surgery & Assistant Surgeon Services
| Reason Code Description | What It Means | Provider Guidance |
|---|---|---|
| Post-Op Follow-Up Included With Global Fee |
The service falls within the global surgical package and is not separately reimbursable. |
Review the applicable global surgery period and previously billed surgical services. |
| Surgeon And Surgical Assist Cannot Be The Same Provider |
The same provider cannot bill as both the primary surgeon and assistant surgeon for the same procedure. |
Verify provider roles and billing information. Submit a corrected claim if necessary. |
| More Than One Assistant Surgeon Not Allowed |
Multiple assistant surgeons were billed when policy allows only one. |
Review surgical billing requirements and verify assistant surgeon eligibility. |
Coverage, Benefits & Frequency Limitations
| Reason Code Description | What It Means | Provider Guidance |
|---|---|---|
| Not A Covered Service |
The service is not covered under the members’ benefit plan. |
Verify coverage and benefits for the date of service before submitting an appeal or inquiry. |
| Not A Covered Service For Provider Specialty |
The service is not reimbursable based on the rendering provider’s specialty. |
Verify specialty-specific reimbursement requirements and provider credentials. |
| Only One Service Allowed Per Course Of Treatment |
The service has exceeded the allowable frequency limitation. |
Review prior claims and applicable frequency limitations before resubmitting. |
| This Procedure/Service Is Not Allowed Because Alternative Services Are Available |
The billed service is not reimbursable because an alternative covered service exists. |
Review plan guidelines and alternative treatment options that may be eligible for reimbursement. |
Billing Units & Transportation Services
| Reason Code Description | What It Means | Provider Guidance |
|---|---|---|
| Adjusted Units Because They Exceeded The Amount Allowed | The number of units billed exceeded policy or code-specific limitations. |
Review unit reporting requirements and supporting documentation. |
| Ambulance Service With Inappropriate Modifier | The modifier submitted does not support the ambulance service billed. |
Review ambulance billing requirements and ensure modifier usage accurately reflects the transport circumstances. |
National Correct Coding Initiative (NCCI)
| Reason Code Description | What It Means | Provider Guidance |
|---|---|---|
|
National Correct Coding Initiative Denial For Column I/ Column II Procedures With Coding Validation |
The service code should not be reported or reimbursed separately because one service code is included in the other. | Review coding and billing practices to ensure alignment with National Correct Coding Initiative (NCCI) guidelines. |
|
National Correct Coding Initiative Denial For Mutually Exclusive Procedures |
Mutually exclusive procedures are services that generally would not be expected to be performed together on the same patient, by the same provider, on the same day. | |
| National Correct Coding Initiative Denial For Mutually Exclusive Procedures With Coding Validation | The service code are subject to NCCI coding edits that generally do not allow separate reimbursement for the procedures when reported together. |
Frequently Asked Questions
Why was my procedure code changed during claim processing?
In some cases, a submitted procedure code may be reviewed and processed under a different procedure code when supported by claim information, coding guidelines, or medical record documentation. Review the remittance advice and supporting documentation for additional details.
Why was a service included in another procedure?
Certain services may be considered incidental, bundled, or inclusive to a primary procedure and therefore may not be separately reimbursable. Review services billed on the same date of service and applicable coding guidelines.
Why was my claim denied as “Not a Covered Service”?
Some services may not be covered under the member’s benefit plan, benefit limitations, or applicable plan guidelines. Providers should verify member eligibility and benefits for the date of service.
Why was my service denied due to provider specialty?
Certain services may only be reimbursable when performed by eligible provider specialties. Providers should verify specialty-specific coverage and reimbursement requirements.
What should I do if additional documentation is requested?
Submit the requested medical records, operative reports, treatment notes, or other supporting documentation identified in the remittance advice to allow for further review of the claim.
Why was my diagnosis code deemed incompatible with the procedure billed?
Claim processing systems review whether the submitted diagnosis code(s) support the billed procedure based on coding guidelines and policy requirements. Providers should review diagnosis and procedure code combinations for accuracy and clinical support.
Why was my Evaluation and Management (E/M) service level changed?
The submitted E/M level may be reviewed and adjusted when documentation supports a different level of service. Providers should ensure documentation supports the billed level in accordance with applicable coding guidelines.
Why was only one E/M service allowed on the same day?
Certain policies may limit the reimbursement of multiple E/M services billed by the same provider group or specialty on the same date of service. Providers should review documentation supporting separate and distinct services.
Why was my add-on code denied?
Some add-on procedures require a qualifying primary procedure. Add-on codes may be denied if the primary procedure was not identified on the claim or was not eligible for reimbursement. Review coding guidelines and claim billing.
Why was my post-operative service denied?
Certain post-operative services may be included in the global surgical allowance and are not separately reimbursable during the applicable global surgery period. Review the surgical procedure and applicable global period guidelines.
Inquiries about Processed Claims
If you believe a claim was incorrectly paid or processed, you may initiate an inquiry by contacting Provider Correspondence.
Please include the claim number, member information, date of service, disputed service or claim line, reason for the inquiry, and supporting documentation, as applicable. HMSA will review the available information and reprocess the claim if warranted. Additional inquiries may be submitted if new information becomes available or questions remain unresolved.
Reference Document
- Physician Appeals
- Medicare Advantage Provider Appeals
- QUEST Integration – Provider Reconsiderations, Grievances, and Appeals Process
- Non-Physician Appeals (Excluding Facilities)
- Appealing Processed Claims
- HHIN+ Login
Revision History
| Date | Nature of Revision |
|---|---|
| 09/11/2026 | First published. |