Provider Adjustment Reason Codes

X12 External Code Source 967 3/1/2019 LAST UPDATED

These codes report payment adjustments that are not related to a specific claim, bill, or service.

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01Card interchange fee amount
Start: 10/01/2018
02Advanced or accelerated payment recoupment amount
Start: 03/01/2019
03Claim transmission fee amount
Start: 03/01/2019
50The amount of the late charge, late claim filing penalty, or Medicare late cost report penalty.
Start: 07/01/2018
51Late filing interest penalty assessment amount
Start: 07/01/2018 | Last Modified: 03/01/2019
72Provider refund amount
This adjustment acknowledges a refund received from a provider for previous overpayment.
Start: 07/01/2018 | Last Modified: 03/01/2019
90Early payment allowance amount
Start: 07/01/2018
AHClaim transmission fee amount
This code is used for transmission fees that are not specific to or dependent upon individual claims.
Start: 07/01/2018 | Last Modified: 03/01/2019
AMLoan repayment amount
Start: 07/01/2018 | Last Modified: 03/01/2019
APAccelerated adjustment amount
Start: 07/01/2018
B2Rebate amount
Applies when a provider has remitted an over payment to a health plan in excess of the amount requested by the health plan.
Start: 07/01/2018 | Last Modified: 03/01/2019
B3Recovery amount
This represents the amount received from the provider for an overpayment based on payments from other payers. This code is not used for other provider refund adjustment amounts.
Start: 07/01/2018 | Last Modified: 03/01/2019
BDBad debt amount
Start: 07/01/2018 | Last Modified: 03/01/2019
BNBonus amount
Start: 07/01/2018
CRCapitation interest amount
Start: 07/01/2018
CSAdjustment amount, detailed information is provided separately to explain the adjustment.
Start: 10/01/2018
CTCapitation payment amount
Start: 07/01/2018
E3Withholding amount
Start: 07/01/2018 | Last Modified: 03/01/2019
FBNon-claim related balance forward amount
Start: 07/01/2018 | Last Modified: 03/01/2019
FCAllocation of prepaid funds against which deductions are drawn as services are provided.
Start: 03/01/2019
FRClaim-related balance forward amount
Start: 03/01/2019
HMHemophilia clotting factor add-on payment amount
Start: 03/01/2019
IPIncentive payment amount
Start: 10/01/2018
IRInternal Revenue Service 1099 withholding amount
Start: 03/01/2019
J1Amount not reimbursed based on a demonstration program or other limitation that prevents issuance of payment.
Start: 03/01/2019
L3Penalty amount
Start: 10/01/2018
L6Interest amount
Start: 03/01/2019
LEInternal Revenue Service non-1099 withholding amount
Start: 03/01/2019
OBAffiliated provider(s) offset amount
Start: 10/01/2018
PIPeriodic Interim Payment (PIP) lump sum amount
Start: 03/01/2019
PLFinal payment or settlement amount
Start: 10/01/2018
RARetroactive adjustment amount
Start: 10/01/2018
SLStudent loan garnishment amount
Start: 10/01/2018 | Last Modified: 03/01/2019
TLThird party liability determination amount
Start: 03/01/2019
WOOverpayment recovery amount
Start: 10/01/2018