Provider Claims Review and Resolution Guide

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.

Select options below for additional information

Frequent Asked Questions	Quick answers to common questions about claims reviews, reprocessing, and provider inquiries
Inquiries about Processed Claim	Submit an inquiry for claims believed to be processed incorrectly. HMSA will review and reprocess the claim if warranted.

Enhanced Claim Editing Payment Policy	Message Codes
Add-on Code Policy	B049, W019AI
Assistant Surgeon Policy	B051, W010, W014, W161
Bilateral Procedures Policy	W029
Bundled Facility Payment Policy	B050, W031
Bundled Services Policy	W032, W187
Claims Processing Parameters Policy	W088, W090, W104AI, W113AI, W167
CMS Coverage Policies	B066AI, W025, W037A, W074, W168, W210, W212AI, W214, W225
Co-Surgeon Policy	W040, W163
Coding & Documentation Reviews	B001, W003, W030, W183AI, W203, W218
Coverage, Benefits & Frequency Limitations	W004, W005, W017, W042, W087, W155
Deleted HCPCS Codes Policy	W070AI
Device and Supply Policy	W115
Diagnosis-Age Policy	W079AI
Diagnosis Code Guideline Policy	W011AI, W071AI, W082AI, W179AI
Diagnosis-Gender Policy	W080AI
Diagnosis Validity Policy	W106AI, W197
Duplicate Services Policy	B055, W194
Durable Medical Equipment and Supplies Policy	W033, W073, W100, W186AI, W211
Drug and Biological Policy Processing and Policy Guidelines	W075, W157AI, W159AI
Evaluation and Management Services Policy	B054, B058, W012AI, W078, W086AI
Frequency Policy	W020, W173
Global Obstetrical Policy	W171
Global Surgery Policy	B059, W006, W069
Incident To Services Policy	W102
Miscellaneous	W002, W015, W112, W135, W156
Modifier Policy	W013, W072, W107AI, W137AI, W138
National Correct Coding Initiative Policy	B053AI, B056, W034, W035AI
National Correct Coding Manual Policy	B061, B062, B063AI, W016
Observation Services Policy	W172
Partial Hospitalization Policy	W095, W182, W193AI
Place of Service Policy	W190
Professional, Technical, and Global Services Policy	W220
Procedure Code Definition Policy	B060, W176
Procedure Code Guideline Policy	B067, W177
Procedure-Age Policy	W043, W045
Procedure-Gender Policy	W046AI, W047
Revenue Code Policy	W111, W200, W207, W208AI, W209AI
Separate Procedures Policy	W215
Split Surgical Care Policy	W216
Team Surgery Policy	W221

Add-On

RTP Message Code	High-Level Explanation	Provider Next Steps
B049	The Add-On Code Was Denied Because The Primary Procedure Was Denied On Coding Validation	Submit an appeal with medical records supporting why the add-on service and related primary procedure are separately reimbursable.
W019AI	This procedure was denied because it is an add-on code that requires a primary procedure to be billed with it.	Submit a corrected claim with the required primary procedure.

Assistant Surgeon

RTP Message Code	High-Level Explanation	Provider Next Steps
B051	This code billed has been denied as the primary surgeon and the assistant surgeon codes do not match based on Coding Validation.	Submit an appeal with the operative report and documentation supporting the primary surgeon and assistant surgeon roles and procedure codes billed.
W010	This code cannot be paid as a Surgical assist when the same provider has submitted this code also as the primary surgeon.	Submit a corrected claim if the provider role or assistant surgeon modifier was reported incorrectly.
W014	Only one assistant surgeon is allowed for the procedure submitted.	Submit a corrected claim if the provider roles, procedure codes, or modifiers were reported incorrectly.
W161	Procedure denied. The procedure code billed does not require the services of an assist.	Submit a corrected claim if the provider roles, procedure codes, or modifiers were reported incorrectly.

Bilateral Procedures

RTP Message Code	High-Level Explanation	Provider Next Steps
W029	This procedure was adjusted because the service is bilateral in nature.	Submit a corrected claim if the bilateral procedure or modifier was reported incorrectly.

Bundled Facility Payment

RTP Message Code	High-Level Explanation	Provider Next Steps
B050	This claim was evaluated using Inpatient Re-Admission criteria against a previous claim for this member	Submit an appeal with the prior/current admission records supporting the separate nature of the readmission.
W031	The payment for this service is considered inclusive of the facility payment and is not separately payable.	Submit a corrected claim if the information affecting separate reimbursement was reported incorrectly.

Bundled Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W032	The service is considered bundled into another service or payment and is not separately reimbursable.	Submit a corrected claim if the information affecting separate reimbursement was reported incorrectly.
W187	The service is considered incidental or packaged into another payment.	Submit a corrected claim if the information affecting separate reimbursement was reported incorrectly.

Claims Processing Parameters

RTP Message Code	High-Level Explanation	Provider Next Steps
W088	The billed procedure was denied because the claim receive date exceeded the timely filing period.	Submit provider inquiry with proof of timely filing if you disagree with this determination.
W090	This health service code was denied because records show that this patient has previously been reported as expired.	Submit a corrected claim if the member information was reported incorrectly.
W104AI	This health service code was denied because the discharge status code is invalid.	Submit a corrected claim with the appropriate discharge status code.
W113AI	International Classification of Disease (ICD) procedure code listed on the claim is invalid	Submit a corrected claim with the appropriate ICD-10 diagnosis.
W167	This claim was denied because the Type of Bill indicates that it is not payable	Submit a corrected claim with the appropriate bill type.

CMS Coverage

RTP Message Code	High-Level Explanation	Provider Next Steps
B066AI	The billed service was denied because the incorrect Discharge Status Code was used as per guidelines	Submit an appeal with discharge records and clinical notes supporting the discharge status reported on the claim.
W025	Coverage for the billed service requires adjustment request.	Submit the appropriate corrected claim.
W037AI	Clinical Research Studies require appropriate diagnosis	Submit a corrected claim with the appropriate diagnosis code when applicable.
W074	This health service code was denied as a procedure billed with a Durable Medical Equipment (DME) only indicator should be billed to Durable Medical Equipment Regional Carrier (DMERC).	Submit the service to the appropriate DME contractor (DME MAC/DMERC).
W168	Payment for services is denied when performed by this specialty/provider type in this place of service.	Submit a corrected claim if the provider information or place of service was reported incorrectly
W210	The billed services were denied because the revenue code is not recognized by Medicare	Submit a corrected claim with a Medicare-recognized revenue code.
W212AI	This health service code was denied because a required secondary diagnosis code is missing or invalid.	Submit a corrected claim with the required valid secondary diagnosis code.
W214	The billed services were denied because services on the Separate Payment for Services not Provided by Medicare list must be submitted with the appropriate Bill Type.	Submit a corrected claim with the appropriate bill type.
W225	This health service was denied because the wrong procedure was performed.	Submit a corrected claim only if the procedure code or related claim information was reported incorrectly.

Co-Surgeon Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W040	Co-surgeon services are not payable when the providers are from the same subspecialty.	Submit a corrected claim if the provider roles, procedure codes, or modifiers were reported incorrectly.
W163	Co-surgeon reimbursement is not allowed for the billed procedure.	Submit a corrected claim if the provider roles, procedure codes, or modifiers were reported incorrectly.

Coding & Documentation Reviews

RTP Message Code	High-Level Explanation	Provider Next Steps
B001	The billed procedure was recoded to a more appropriate procedure code based upon information provided on the claim or in the patient's history.	Submit an appeal with clinical notes supporting the originally billed procedure code.
W003	This CPT code has been changed to reflect a more appropriate code based on the circumstances in which it was billed.	Submit a Provider Inquiry if the code change was not appropriate or submit a corrected claim with the appropriate procedure code.
W030	This procedure was denied because it requires that an accompanying procedure be billed on the same date of service by the same or different provider.	Submit a corrected claim if the required accompanying procedure was omitted or reported incorrectly.
W183AI	This CPT code has been denied based on the circumstances in which it was billed.	Submit a corrected claim with the appropriate procedure code.
W203	Based on the other procedures billed for this date of service, this procedure was re-coded with a procedure that represents complete service.	Submit a Provider Inquiry if the code change was not appropriate or submit a corrected claim with the appropriate procedure code.
W218	Patient history indicates that this service/CPT code has been recently performed by same and/or different provider for the same condition.	Submit a corrected claim if the procedure, diagnosis, provider information, or date of service was reported incorrectly; otherwise, submit a provider inquiry if the service was not previously performed for the same condition

Coverage, Benefits, & Frequency Limitations

RTP Message Code	High-Level Explanation	Provider Next Steps
W004	The service is not covered under the member’s benefit plan or applicable coverage guidelines.	Submit a provider inquiry with documentation supporting coverage of the service under the member’s benefit plan.
W005	The service is not reimbursable based on the rendering provider’s specialty.	Submit a corrected claim if the rendering provider or specialty was reported incorrectly or submit a provider inquiry with documentation supporting specialty eligibility.
W017	The allowed course of treatment for this CPT code has been exceeded.	Submit a corrected claim if the course of treatment, units, or dates of service were reported incorrectly
W042	This health service code was denied as this service exceeds the frequency limitations contained in the policy or contract.	Submit a corrected claim if the frequency of services reported on the claim was incorrect.
W087	Based on clinical guidelines, the criteria for billing this code have not been met.	Submit a corrected claim if the procedure code, diagnosis code, or other claim information was reported incorrectly.
W155	This health service code was denied as it is not a covered service when billed with the submitted diagnosis code.	Submit a corrected claim with the appropriate diagnosis for services billed.

Deleted HCPCS Codes

RTP Message Code	High-Level Explanation	Provider Next Steps
W070AI	The procedure code billed was not valid for the reported date of service.	Submit a corrected claim with a procedure code valid for the date of service.

Device and Supplies

RTP Message Code	High-Level Explanation	Provider Next Steps
W115	This implant procedure code was denied because the associated implant device was not billed for the same date of service.	Submit a corrected claim with the associated implant device.

Diagnosis Codes

RTP Message Code	High-Level Explanation	Provider Next Steps
W011AI	The diagnosis code submitted on the claim does not support the procedure code billed based on coding or policy requirements.	Submit a corrected claim with a diagnosis code that supports the billed procedure.
W071AI	The billed diagnosis code(s) was inappropriately coded based on ICD coding guidelines.	Submit a corrected claim with a diagnosis code that complies with ICD coding guidelines.
W079AI	The age of the patient does not correlate with the submitted diagnosis code.	Submit a corrected claim if the diagnosis code or patient age was reported incorrectly.
W080AI	The patient's gender does not correlate with the submitted diagnosis code.	Submit a corrected claim if the diagnosis code or patient information was reported incorrectly.
W082AI	The primary, first-listed or principal diagnosis has been inappropriately coded based upon ICD Manual coding guidelines.	Submit a corrected claim with the appropriate primary, first-listed, or principal diagnosis code.
W179AI	This health service code was denied because it was submitted with an invalid ICD-9 diagnosis code.	Submit a corrected claim with the appropriate updates.
W106AI	The billed diagnosis is not coded to the highest level of specificity.	Submit a corrected claim with the diagnosis coded to the highest level of specificity.
W197	The diagnosis listed on the claim is invalid.	Submit a corrected claim with a valid diagnosis code.

Duplicate Services

RTP Message Code	High-Level Explanation	Provider Next Steps
B055	Services billed on the claim are considered a duplicate submission	Submit an appeal with clinical notes showing that the billed service was separate and distinct from the previously processed service.
W194	This claim has been previously submitted	Submit a corrected claim only if the previously processed claim was reported incorrectly.

Durable Medical Equipment and Supplies

RTP Message Code	High-Level Explanation	Provider Next Steps
W033	The billed equipment was denied because the maximum number of rentals has already been paid.	Verify the rental history and submit a corrected claim if the rental information was reported incorrectly.
W073	Item denied because it is an item of convenience, the item is not medical in nature, and/or does not meet the definition of DME.	Submit a corrected claim if the item was billed incorrectly and meets the definition of DME
W100	This health service code was denied because it is considered to be included in the monthly rental fee of another health service code.	Submit a corrected claim only if the item is not included in the monthly rental fee.
W186AI	This health service code was re-coded to a valid code for Medicare.	Submit a provider inquiry if the procedure code re-coded incorrectly.
W211	This health service/item code was denied because it was not submitted with a modifier which indicates that the requirements specified in the medical policy have been met.	Submit a corrected claim with the appropriate modifier if it was omitted or reported incorrectly

Drug and Biological Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W075	The reported National Drug Code (NDC) number has been denied as it is not approved by the Food and Drug Administration.	Submit a corrected claim if the NDC was reported incorrectly.
W157AI	This NDC was denied because it is invalid	Submit a corrected claim with a valid NDC.
W159AI	The billed NDC code does not match the HCPCS code that it was billed with	Submit a corrected claim with an NDC that matches the billed HCPCS code.

Evaluation & Management (E/M) Services

RTP Message Code	High-Level Explanation	Provider Next Steps
B054	The billed service was denied because it is not consistent with the coverage limitations contained in the guidelines based on Coding Validation Review.	Submit an appeal with clinical notes demonstrating that the service met the applicable coverage requirements.
B058	The billed service was denied because clinical documentation did not support the clinical or medical necessity requirement	Submit an appeal with clinical notes demonstrating that the service met the applicable clinical requirements.
W012AI	This E&M service was denied because only one E&M service is allowed for the same date of service per provider group within the same provider specialty.	Submit a corrected claim if the provider information was reported incorrectly.
W078	The same CPT code (or a similar CPT code) was billed on the same date of service.	Submit a corrected claim only if the previously processed claim was reported incorrectly.
W086AI	The E/M service may not be coded appropriately based on claim or documentation review.	Submit a corrected claim with the appropriate E/M service code.

Frequency

RTP Message Code	High-Level Explanation	Provider Next Steps
W020	The units for the billed CPT code have been adjusted to reflect the allowed amount for this code.	Submit a corrected claim if the units reported exceed the allowable units due to billing error.
W173	The billed code may not be billed with partial units.	Submit a corrected claim with the appropriate units

Global Obstetrical Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W171	This health service code was changed to reflect that the provider did not provide the antepartum and postpartum care based on the information on the claim.	Submit a corrected claim if the claim did not accurately reflect the antepartum and postpartum care services provided.

Global Surgery

RTP Message Code	High-Level Explanation	Provider Next Steps
B059	Services billed on the claim were reviewed and determined included in a global fee.	Submit an appeal with clinical notes supporting why the service is separately reimbursable outside the global fee.
W006	The procedure is included in the global surgical fee for a procedure billed for a previous date of service.	Submit a corrected claim if the procedure, modifier, or date of service was reported incorrectly. If the claim is submitted correctly, submit an appeal with documentation supporting separate reimbursement outside the global fee.
W069	The service is included in a global fee for another procedure.	Submit a corrected claim if the procedure, modifier, or date of service was reported incorrectly. If the claim is submitted correctly, submit an appeal with documentation supporting separate reimbursement outside the global fee.

‘Incident To’ Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W102	The submitted service was furnished as an integral, although incidental, part of the physician's personal professional services during diagnosis or treatment of an illness or injury.	Submit a corrected claim if the service was separately billed or the provider information was reported incorrectly

Miscellaneous

RTP Message Code	High-Level Explanation	Provider Next Steps
W002	The service is considered part of another reimbursable procedure and is not separately payable.	Submit a corrected claim if the information affecting separate reimbursement was reported incorrectly.
W015	The procedure is considered part of the evaluation and management service and is not separately reimbursable.	Submit a corrected claim if the information affecting separate reimbursement was reported incorrectly.
W112	The service is identified as a separate procedure but is not separately payable in the claim context.	Submit a corrected claim if the information affecting separate reimbursement was reported incorrectly.
W135	This health service code was either denied or modified because it is not consistent with the submitted modifier or it was not submitted with a required modifier.	Submit a corrected claim with the appropriate modifier.
W156	The place of service indicated on the claim is not appropriate for this CPT code.	Submit a corrected claim with the appropriate place of service.

Modifiers

RTP Message Code	High-Level Explanation	Provider Next Steps
W013	The modifier submitted is not appropriate for the billed CPT code.	Submit a corrected claim with the appropriate modifier.
W072	Services are not separately reimbursable when billed on the same date as an outpatient facility regarding a discontinued outpatient procedure	Submit a corrected claim, if needed, to ensure the facility and professional services are billed correctly.
W107AI	This procedure was denied because it was billed with a modifier that is inappropriate for the procedure.	Submit a corrected claim with the appropriate modifier.
W137AI	Modifier Inappropriate For Place Of Service	Submit a corrected claim with a modifier appropriate for the reported place of service.
W138	The recommended percentage for this procedure has been adjusted based on the submitted modifier(s).	Submit a corrected claim if the modifier was reported incorrectly on the original claim

National Correct Coding Initiative (NCCI)

RTP Message Code	High-Level Explanation	Provider Next Steps
B053AI	The services are mutually exclusive and were reviewed through coding validation.	Submit an appeal with clinical notes supporting why both mutually exclusive procedures were separately reportable.
B056	The codes billed together are subject to NCCI edits after coding validation review.	Submit an appeal with clinical notes supporting why the Column I and Column II procedures were separate and distinct.
W034	The codes billed together are subject to NCCI edits and one service may be included in another.	Submit a corrected claim if the services qualify for separate payment and were billed with incorrect procedure codes, modifiers, or other claim information.
W035AI	The services billed together are considered mutually exclusive under NCCI rules.	Submit a corrected claim if the services were billed incorrectly and are not mutually exclusive under NCCI guidelines

National Correct Coding Manual

RTP Message Code	High-Level Explanation	Provider Next Steps
B061	Services billed on the claim and determined to be eligible for separate payment.	Submit an appeal with clinical notes supporting the reimbursement determination requested for the service.
B062	Services billed on the claim are considered bundled into another service or payment and are not separately reimbursable.	Submit an appeal with clinical notes supporting why the service is separate and distinct from the primary procedure.
B063AI	The services billed on the claim are determined to be mutually exclusive and only one service is eligible for reimbursement.	Submit an appeal with clinical notes supporting why both mutually exclusive procedures were separately reportable and eligible for separate reimbursement.
W016	This code should not be reported since a similar procedure was performed on the same date of service.	Submit a corrected claim if the procedure was reported incorrectly or qualifies as a distinct service.

Observation Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W172	Observation care code requires minimum of 8 hours, a diagnosis of CHF, Chest Pain, or Asthma, and no T procedure on the same or previous day.	Submit a corrected claim if the observation hours, diagnosis, or related procedure information was reported incorrectly.

Partial Hospitalization Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W095	This health service code was denied because a partial hospitalization requires a mental health diagnosis as the primary diagnosis on the claim.	Submit a corrected claim if the primary diagnosis was reported incorrectly.
W182	This health service code was denied because condition code 41 (Partial Hospitalization) was not documented on the submitted claim.	Submit a corrected claim with condition code 41 when partial hospitalization applies.
W193AI	The health care codes were denied because the Condition Code is not appropriate for the Bill Type.	Submit a corrected claim with a condition code appropriate for the bill type.

Place of Service

RTP Message Code	High-Level Explanation	Provider Next Steps
W190	The place of service on the billed claim line is inconsistent based upon the presence of another claim that indicates the service was performed in a different setting than what was billed on the claim line.	Submit a corrected claim with the appropriate place of service.

Professional, Technical, and Global Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W220	This procedure is billed as a technical component and is therefore not payable for the place of service submitted on the claim.	Submit a corrected claim if the technical component modifier or place of service was reported incorrectly

Procedure Code Definition

RTP Message Code	High-Level Explanation	Provider Next Steps
B060	This billed service was denied as the length of stay is inconsistent with the procedure performed with coding validation.	Submit an appeal with medical records, procedure documentation, and documentation supporting the reported length of stay.
W176	The submitted code was reviewed against the service definition or code requirements.	Submit a corrected claim if the procedure code does not accurately reflect the service provided

Procedure Code Guidelines

RTP Message Code	High-Level Explanation	Provider Next Steps
B067	Services billed on the claim denied based on the circumstances in which it was billed.	Submit an appeal with clinical notes supporting the billed procedure code under the circumstances of the service.
W177	This service code was denied because it is inappropriately coded based on coding manual guidelines.	Submit a corrected claim if the procedure code was reported incorrectly or does not accurately reflect the service provided

Procedure Age

RTP Message Code	High-Level Explanation	Provider Next Steps
W043	The age of the patient does not correlate with the submitted procedure code.	Submit a corrected claim if the procedure code or patient age was reported incorrectly.
W045	The health service code has been changed to correlate to the appropriate age of the patient.	Submit a corrected claim if the procedure code was reported incorrectly.

Procedure Gender

RTP Message Code	High-Level Explanation	Provider Next Steps
W046AI	The gender of the patient does not correlate with the submitted procedure code.	Submit a corrected claim if the procedure code or patient information was reported incorrectly.
W047	The health service code has been changed to correlate to the appropriate gender of the patient.	Submit a corrected claim if the procedure code or patient information was reported incorrectly.

Revenue Codes

RTP Message Code	High-Level Explanation	Provider Next Steps
W111	This health service code was denied because the revenue code is invalid.	Submit a corrected claim with a valid Revenue code.
W115	This implant procedure code was denied because the associated implant device was not billed for the same date of service.	Submit a corrected claim with the associated implant device.
W200	HCPCS code was billed without the appropriate revenue code.	Submit a corrected claim with matching revenue and HCPCS codes.
W207	The billed service was denied because the revenue code associated with it does not match the bill type.	Submit a corrected claim with a revenue code appropriate for the bill type.
W208AI	The billed services were denied because the revenue code was inappropriately coded.	Submit a corrected claim with the appropriate revenue code.
W209AI	The billed services were denied because the revenue code was not submitted with an appropriate HCPCS code.	Submit a corrected claim with matching revenue and HCPCS codes.

Separate Procedures

RTP Message Code	High-Level Explanation	Provider Next Steps
W215	Separate procedures are commonly performed as an integral component of a total service or procedure and should not be reported in addition to the code for the total service or procedure.	Submit a corrected claim if the information affecting separate reimbursement was reported incorrectly.

Split Surgical Care Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W216	Each provider is reimbursed according to the portion of surgical care they provided.	Submit a corrected claim if the portion of surgical care or applicable modifier was reported incorrectly

Team Surgery Services

RTP Message Code	High-Level Explanation	Provider Next Steps
W221	This procedure, billed as a team surgery (66 modifier), was denied because this procedure does not require team surgery	Submit a corrected claim if the provider roles, procedure codes, or modifiers were reported incorrectly.

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

CURRENT AS OF 09/30/2026

Revision History

Date	Nature of Revision
09/30/2026	Updated Quick Reference Guide section.
09/11/2026	First published.