Health Care Service Review Decision Reason Codes • X12 External Code Source 886
LAST UPDATED 11/1/2017

These codes communicate the reason for the health care services review outcome.

Minutes from the September 2017 Meeting. Minutes from previous meetings can be found in the FAQs.

01Price Authorization Expired
Start: 01/10/2001
02Price authorization no longer required
Start: 01/10/2001
03Product not on the price authorization
Start: 01/10/2001
04Authorized Quantity Exceeded
Start: 01/10/2001
05Special Cost Incorrect
Start: 01/10/2001
06No Credit Allowed
Start: 01/10/2001
07Administrative Cancellation
Start: 01/10/2001
08Unit resale higher than authorized
Start: 01/10/2001
09Out of Network
Start: 01/10/2001
0ATesting not Included
Start: 01/10/2001
0BRequest Forwarded To and Decision Response Forthcoming From an External Review Organization
Start: 01/10/2001
0CAuthorization/Access Restrictions
Start: 01/10/2001
0DRequires PCP authorization
Start: 01/10/2001
0EProvider is Not Primary Care Physician
Start: 01/10/2001
0FNot Medically Necessary
Start: 01/10/2001
0GLevel of Care Not Appropriate
Start: 01/10/2001
0HCertification Not Required for this Service
Start: 01/10/2001
0JCertification Responsibility of External Review Organization
Start: 01/10/2001
0KPrimary Care Service
Start: 01/10/2001
0LExceeds Plan Maximums
Start: 01/10/2001
0MNon-covered Service
Start: 01/10/2001
0NNo Prior Approval
Start: 01/10/2001
0PRequested Information Not Received
Start: 01/10/2001
0QDuplicate Request
Start: 01/10/2001
0RService Inconsistent with Diagnosis
Start: 01/10/2001
0SPre-existing Condition
Start: 01/10/2001
0TExperimental Service or Procedure
Start: 01/10/2001
0UAdditional Patient Information required
Start: 01/10/2001
0VRequires Medical Review
Start: 01/10/2001
0WDisposition pending review
Start: 01/10/2001
0XService Inconsistent with Provider Type
Start: 01/10/2001
0YService inconsistent with Patient's Age
Start: 01/10/2001
0ZService inconsistent with Patient's Gender
Start: 01/10/2001
10Product/service/procedure delivery pattern (e.g., units, days, visits, weeks, hours, months)
Start: 01/10/2001
11Pricing
Start: 01/10/2001
12Patient is restricted to specific provider
Start: 01/10/2001
13Service authorized for another provider
Start: 01/10/2001
14Plan/contractual guidelines not followed
Start: 01/10/2001
15Plan/contractual geographic restriction
Start: 01/10/2001
16Inappropriate facility type
Start: 01/10/2001
17Time limits not met
Start: 02/01/2002
18Notification received
Start: 06/01/2002
19Cosmetic
Start: 06/01/2002
20Once in a lifetime restriction applies
Start: 02/01/2004
21Transport Request Denied
Start: 06/01/2004
22Ambulance Certification Segment information doesn't correspond to Transport Address Segment
Start: 06/01/2004
23Mileage cannot be computed based on data submitted
Start: 06/01/2004
24Computed mileage is inconsistent with transport information or service units submitted
Start: 06/01/2004
25Services were not considered due to other errors in the request.
Start: 06/06/2010
26Missing Provider Role
Start: 06/05/2011
27Patient is currently in a Health Insurance Exchange premium payment grace period -- first month. Usage: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014 | Last Modified: 07/01/2017
28Patient is currently in a Health Insurance Exchange premium payment grace period -- second month. Usage: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014 | Last Modified: 07/01/2017
29Patient is currently in a Health Insurance Exchange premium payment grace period -- third month. Usage: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014 | Last Modified: 07/01/2017
30Initial Utilization Review In Progress
Start: 11/01/2017
31Escalated Utilization Review in Progress
Start: 11/01/2017