HCF Web User Manual - Chapter 9: Reason Codes Utilized
Contents
1. Note Insurers are required to respond to OCF 18s and 23s within the SABS timelines The use of the Pending status does not eliminate the requirement for responses D Category 00 Missing or Incomplete Information 3 00 00 Application for benefits missing or incomplete 3 00 05 Statement under oath not yet complete Source Health Claims for Auto Insurance Processing 3 o Category 01 Coordination of Benefits camerei 3 02 00 Policy coverage identity error ee EE II IC ac Pending agreement by all parties Series 4 Withdrawn PF Category 00 By Provider 4 00 00 Withdrawn on behalf of the provider Category 01 By Claimant 4 01 00 Withdrawn on behalf of the claimant Category 02 By Data Entry Centre 4 02 00 Withdrawn on behalf of the DEC Category 03 By Insurer 4 03 00 Withdrawn on behalf of the insurer Series 5 Information pespion Category 00 Authorization Reached 5 00 00 Authorized quantity reached try oF Aerating coverage tints Source Health Claims for Auto Insurance Processing 42. FACILITY WEB MANUAL June 2011 CHAPTER 9 REASON CODES UTILIZED BY ADJUSTERS WHAT ARE REASON CODES SERIES 1 ADJUSTER DECISION SERIES 2 ADJUSTER DECISION UPDATE SERIES 3 PENDING SERIES 4 WITHDRAWN SERIES 5 INFORMATION fs AS CP Ce a CHAPTER 9 Reason Codes Utilized by Adjusters What Are Reason Codes When insurance adjusters make an adjudication decision they must specify the reason behind the decision The list of approval reason codes used in the HCAI application falls within five series Adjuster Decision Adjuster Decision Update Pending Withdrawn Information Each code consists of three groups of numbers 1 The first number series 2 The middle two numbers category 3 The last two numbers reason Example Code 1 00 05 means the following e Series 1 Adjuster Decision e Category 00 Invalid Authorization e Reason 05 Authorization number error Series 1 Adjuster Decision a Category 00 Invalid Authorization Authorization number required Authorization number error No record of authorization Po Category 01 Authorization Required Product service requires prior authorization ui Category 02 Authorization Exceeded Authorized quantity exceeded Authorized amount exceeded Authorized unit cost exceeded Po Category 03 Authorization Period Prior to authorization eligible period Authorized time period exceeded Category 04 Pre Approved Framework PAF and
3. Other Bill 198 Changes 1 04 00 PAF Guideline exceeded Source Health Claims for Auto Insurance Processing 1 04 05 Good or service is not covered within the PAF Guideline Good or service is not separately reimbursable within 1 04 10 PAF Diagnosis indicates that another PAF is appropriate Games pat at severe Fed OOOO Ceea OOO sy aon are series OOOO Cee oae O DN 7 ca Spi mon O a Policy coverage limits exceeded Source Health Claims for Auto Insurance Processing 2 1 11 20 Patient must claim reimbursement 1 11 25 Good or service not covered Category 12 Financial Charges 1 12 00 GST is incorrect or not applicable 1 12 05 PST is incorrect or not applicable 1 12 10 Interest is incorrect or not applicable Category 13 Coordination of Benefits 1 13 00 Collateral insurance missing or incorrect Category 14 Conflict of Benefits 1 14 00 There is a conflict of interest Category 15 Other 1 15 00 Claimant signature is required Series 2 Adjuster Decision Update Po Category 00 Decision Update of Claim 2 00 00 Decision updated in accordance with a binding medical Bas opinion Decision updated in accordance with a binding 2 00 05 a eae l arbitration or litigation ruling 2 00 10 Decision updated based on new information received 2 00 15 Decision updated because of conflict of interest 2 00 20 Decision updated based on agreement by all parties Series 3 Pending
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