Explanation of Payment Message Codes

 

Code	Message
01	Frame not authorized.
02	Lens not authorized.
03	Exam not authorized.
04	Fee reduced due to late submission.
05	Frame over limit.
06	Doctor’s redo.
07	Secondary COB claim.
08	Adjustment
09	Value plan only – exam billed as new patient – downcoded to established.
10	Interest payment associated with late payment of a claim.
15	Your primary insurance coverage reimbursed expenses in full.
17	Primary COB claim.
20	Changed doctor information
21	Changed lab ID information
22	Changed benefit form (claim) number
23	Changed benefit form information
24	Changed assignee information
25	Additional changes made
26	Changed lab invoice number
27	Changed group information
28	In-Office Finishing Claim Adjustment.
2H	In-Office Finishing service is not allowed for the benefit type
2I	In-Office Finishing option code is not allowed with other options billed
2J	Unapproved lab was used for this In-Office Finishing service
2K	Service is not payable due to related In-Office Finishing service being denied
30	Deleted exam service
31	Deleted lens service
32	Deleted frame service
33	Deleted contact lens service
34	Deleted treatment service
35	Deleted lens option service
36	Deleted miscellaneous service
39	A material code is required with dispensing services.
3A	A valid date of service is required (CMS-1500 box 24a).
3B	Date of service is after the claim received date (CMS-1500 box 24a).
3C	Units exceed the allowed amount for this procedure (CMS-1500 box 24g).
3D	Anesthesia units must reflect the number of minutes spent with the patient (CMS-1500 box 24g).
3E	Service requires an appropriate modifier (CMS-1500 box 24d).
3F	Inappropriate billing of modifiers (CMS-1500 box 24d).
3G	Place of service is inappropriate for service billed (CMS-1500 box 32).
3H	Place of service and modifier combination is not appropriate (CMS-1500 boxes 32 & 24d).
3I	Place of service is not valid (CMS-1500 box 32).
3J	Service requires a primary medical eyecare diagnosis (CMS-1500 box 21).
3K	Diagnosis code is not appropriate for this benefit (CMS-1500 box 21).
3L	Diagnosis referenced is not appropriate for the service (CMS-1500 box 21).
3M	Diagnosis code combination is not appropriate (CMS-1500 box 21).
3N	At least one primary eyecare diagnosis is required (CMS-1500 box 21).
3O	A valid diagnosis code is required (CMS-1500 box 21).
3P	Service code is not valid (CMS-1500 box 24d).
3Q	Material code must be accompanied by the appropriate service code (CMS-1500 box 24d).
3R	An accompanying service code was not billed (CMS-1500 box 24d).
3S	Option/service code combination is not appropriate (CMS-1500 box 24d or Lab Information/Option Codes section of the Materials Invoice or the Basic Form).
3T	All claim lines must have a valid procedure code (CMS-1500 box 24d).
3U	Service code is not allowed with other services billed (CMS-1500 box 24d).
3V	Service is a non-specific code (CMS-1500 box 24d).
3W	If there is a lens HCPCS code, a corresponding lens type must be provided (Lens Type section of the Materials Invoice or the Basic Form).
3X	If there is a lens type, a corresponding lens HCPCS code must be provided, or the check box was not selected on the Materials Invoice form.
3Y	Lens HCPCS code does not match the corresponding lens type code (CMS-1500 box 24d and the Lens Type section of the Materials Invoice or the Basic Form).
3Z	A frame supplier must be indicated (Frame Service/Frame Supplied By section of the Materials Invoice or the Basic Form).
40	Added exam service
41	Added lens service
42	Added frame service
43	Added contact lens service
44	Added treatment service
45	Added lens option service
46	Added miscellaneous service
4A	A frame supplier and wholesale frame cost must be supplied (Frame Service/Frame Supplied By and Frame Cost sections of the Materials Invoice or the Basic Form).
4B	A frame HCPCS code must be provided.
4C	Frame service requires a wholesale frame cost (Frame Service/Frame Cost section of the Materials Invoice or the Basic Form).
4D	A lab ID is required (Lab ID Code section of the Materials Invoice or the Basic Form).
4E	Lab is not active on date of service.
4F	A lab invoice is required (Lab Information/Invoice # section of the Materials Invoice or the Basic Form).
4G	There is indication of another health plan (CMS-1500 boxes 9a-d or 11a-d). Submit the proper forms from the other insurance company.
4H	Copy of patient’s membership card is required.
4I	Service requires supporting documentation.
4J	Documentation submitted does not support the medical necessity for this procedure.
4K	Patient’s medical record is required.
4L	Submit documentation summarizing treatment to date and ongoing treatment plan.
4M	Service requires precertification from VSP.
4N	Service requires precertification and an invoice to be submitted.
4O	Claim billed with V58.69 or V67.51 requires a secondary diagnosis code that describes the disease state (CMS-1500 box 21).
4P	Indicate if patient is covered by another health plan (CMS-1500 boxes 9a-d or 11a-d).
4Q	Documentation was not submitted prior to providing services.
4R	Patient’s date of birth is required (CMS-1500 box 3).
4S	A valid member ID is required (CMS-1500 box 1a).
4T	Patient’s full name is required (CMS-1500 box 2).
4U	Patient’s signature or signature on file is required (CMS-1500 boxes 12 & 13).
4V	Patient relationship does not match VSP records (CMS-1500 box 6).
4W	Name on the referral does not match the patient’s name (CMS-1500 box 2).
4X	Service date is prior to the referral date (CMS-1500 box 24a).
4Y	A VSP referral is required.
4Z	Referring doctor’s name and NPI are required (CMS-1500 boxes 17 & 17b).
50	Changed service date
51	Changed exam service
52	Changed lens service
53	Changed frame supplier
54	Changed contact lens service
55	Changed treatment service
56	Changed lens option service
57	Changed miscellaneous service
5A	Referral has expired for this service.
5B	Date on referral form is missing.
5C	Self-referral by rendering doctor is inappropriate.
5D	Your Medicaid ID number is not on file with VSP.
5E	Service requires the name of the VSP Primary Eyecare Doctor.
5F	Rendering doctor’s full name is required (CMS-1500 box 31).
5G	Physical address is required (CMS-1500 box 32).
5H	Rendering doctor’s signature is required (CMS-1500 box 31).
5I	Federal Tax ID is required (CMS-1500 box 25).
5J	Rendering doctor’s NPI is required (CMS-1500 box 24J).
5K	Doctor’s signature date is later than the claim received date at VSP (CMS-1500 box 31).
5L	Doctor not eligible to provide services billed.
5M	Coordination of Benefit is not allowed per Client provisions.
5N	Service code is not a covered service for the patient.
5O	Patient is not eligible for the service provided.
5P	Service is not a covered benefit for the patient.
5Q	Service is not payable due to a related service paid in patient’s history.
5R	Service was previously paid in the last 12 month period.
5S	Billing address is required (CMS-1500 box 33).
5T	Service is not payable when billed in the global period of a related service.
5U	From/to dates of service exceed post-op care period (CMS-1500 box 24a).
5V	Comprehensive exam was found in history & was downcoded to an intermediate exam.
5W	Technical and Professional components should not be billed separately by the same provider.
5X	This service is included in the reimbursement of another procedure billed for this date of service.
5Y	Post-op/Pre-op visits are not separately payable within global period of surgery.
5Z	This procedure is not reimbursed when performed during a surgical global period.
60	Changed exam billed amount
61	Changed lens billed amount
62	Changed frame billed amount
63	Changed contact lens billed amount
64	Changed treatment billed amount
65	Changed lens option billed amount
66	Changed miscellaneous billed amount
68	Claim paid twice
69	Claim paid in error
6A	Procedure is included in reimbursement of a previously paid global service.
6B	Patient condition indicates third party liability.
6C	Patient is ineligible for VSP Medical Eyecare Benefits provided by a non-VSP provider/location.
6D	Services not a VSP covered benefit. Refer to health plan.
6E	Service has previously been paid.
6F	Service provided by assistant surgeon is not payable.
6G	VSP medical guidelines were not followed.
6H	Claim was submitted beyond allowed submission period.
6I	A VSP Referral from a primary care provider is required for this procedure.
6J	Option code is not allowed with the other options billed.
6K	Accompanying option code was not billed.
6L	Option code is not allowed with the billed lens type.
6M	Option code is not allowed for the benefit type.
6N	Option code is not valid at date of service.
6O	Criteria has not been met for the service code.
6P	Options are not allowed unless there is a lens service code.
6Q	Service code is not allowed for benefit type.
6R	Claim resubmitted beyond the VSP 180-day allowed re-submission period.
6S	Service is not payable due to related service being denied.
6T	Patient has exhausted allowance.
6U	Service exceeds frequency allowance.
6V	Service has been combined and processed under the exam for same date of services.
6X	Patient not covered by plan for date of service.
6Y	Rendering provider information for date of service doesn’t match VSP systems.
6Z	Patient must be covered by more than one VSP Group.
70	Changed patient name
71	Changed patient relation code
72	Changed patient DOB
74	Changed group information
75	Changed deductible information
76	Changed exclusion information
77	Updated frame code
78	Updated contacts allowance
79	Updated grid code
7A	Date of service is not within the effective dates of the BR.
7B	Service code billed is not appropriate for patient.
7C	Service line amount is required.
7D	Billed amount was not entered or the service(s) is payable at $0.00 (CMS-1500 box 24f).
7E	Refraction service (92015) billed without an exam is not a payable service.
7F	Service is only payable to a licensed or qualified resident physician.
7G	Lens Dispensing was modified to match materials provided by Lab.
7H	Member is under the Access Plan which is a discount only benefit.
7I	Option code is only payable once per date of service.
7J	Remaining services will be processed on a separate claim.
7K	Refer to Provider Reference Manual under Covered and Non-Covered Options.
7L	Frame service requires a retail frame cost.
7M	Submit the birth date of each Member who provides coverage for this dependent.
7N	Submit a complete copy of the Explanation of Benefits (EOB), including the message code explanations, itemized services, amount(s) paid, applied to the deductible, or services denied.
7O	A copy of the original CMS-1500 or claim form that was submitted to the primary insurance carrier is needed.
7P	The name and address of the contract lab is necessary. If an independent lab was used, submit a copy of the optical invoice and include the wholesale cost of materials (Lab Information/Lab ID Code section of the Materials Invoice or the Basic Form).
7Q	Patient has no out-of-pocket expenses left to coordinate.
7R	Service code not billed to the primary insurance.
7S	COB allowed for co-pays only.
7T	Refer to Provider Reference Manual, COB Rules 2 & 3.
7U	Refer to Provider Reference Manual, COB Rule 7.
7V	Refer to Provider Reference Manual, COB Rule 5.
7W	Coordination of Benefits only allowed with Medicare.
7X	Claim or attachment(s) are not legible and cannot be processed. Resubmit a legible copy.
7Y	Documents indicate that VSP is tertiary. Itemized EOB from secondary carrier is required.
7Z	Add-on fees are necessary for non-covered options.
80	Changed member ID.
81	Changed member name
82	Changed member address
83	Changed member city
84	Changed member state
85	Changed member zip code
86	Changed COB total amount
87	Services reversed. Dr to pay lab.
88	Special lens
89	Per doctor’s request
8A	Lens type is needed.
8B	Contact lens type is needed.
8C	The U&C contact lens fee is needed.
8D	Frames are dispensed by the lab for this client.
8E	Unapproved lab was used for this client.
8F	Polycarbonate option has been covered in full for monocular diagnosis.
8G	CMS-1500 billed amount and EOB billed amount does not match (CMS-1500 box 24f).
8H	Product name is required.
8I	Services can only be rendered by a VSP credentialed doctor.
8J	Diagnosis code is not allowed as primary (CMS-1500 box 21).
8K	Primary diagnosis code is blank (CMS-1500 box 21).
8L	Copay added to allowed amount for contact lens professional or material services if total billed charges exceed ECL allowance.
8M	Billed amount has been rolled up to a related service to maximize payment.
8N	Adjustment on Exam Plus or Access Indemnity to maximize provider payment.
8O	Standard option code is not allowed with a progressive option code.
8P	Glass option code is not allowed with a plastic option code.
8Q	Frame has been denied; therefore, frame case is not covered.
8R	Frame case has not been billed; therefore, frame case is not covered.
8S	Frame case is only covered if frame is supplied by the lab or doctor.
8T	Effective February 26, 2005, to be reimbursed for an eyeglass case, you must bill HCPCS code V2756 with your U&C fee for case. VSP will pay the billed amount up to $2.00.
8U	Service is not payable due to related service being denied.
8V	HCPCS service code added per material invoice.
8W	Documentation submitted does not support the necessity for this procedure.
8X	Claim denied per doctor’s request.
8Y	CLCP Qualified patient—initial supply
8Z	COB amount includes out-of-pocket expense from past service in the same service/calendar year.
90	Per lab’s request
91	N in grid
9A	Effective August 27, 2004, bill HCPCS code V2756 for an eyeglass case.
9B	Frame collection type is required.
9C	Does not meet qualification for special lens reimbursement.
9D	The patient's plan does not have an allowance for special lenses.
9E	Frame is not from the approved Titmus collection.
9F	COB amounts include out of pocket expenses using service for service application.
9G	Refer to Provider Reference Manual, COB Rule 4.
9H	The date of service billed on the CMS-1500 does not match the date of service on the Explanation of Benefits.
9I	Refraction is not allowed with the examination billed.
9J	Maximum allowance for materials has been met.
9K	Refraction service is not payable if billed without an exam or if the exam is denied.
9L	The secondary exam allowance includes exam and refraction overages.
9M	Second or subsequent lens re-dos are private transactions between you, the lab and the patient.
9N	Member share of cost has been deducted from the allowed amount.
9O	The member's share of cost must be entered in box 29 on the CMS-1500 form.
9P	Member share of cost exceeds claim allowance.
9Q	Original claim number previously submitted. New claim number assigned by VSP.
9R	The service billed was not issued on the claim authorization.
9S	The service billed was not issued on the claim authorization.
9T	Exam billed is not payable due to an exam in patient's history for the same date of service.
9U	Claim has been corrected to add fitting of spectacle and/or modifier.
9V	Misdirected claim, re-submit to: THMP, P.O. Box 200555, Austin, TX 78272.
9W	Routine ophthalmological examination reimbursement includes refraction.
9X	99xxx codes are not payable for routine/supplemental exams. Please bill using 92002-92014.
9Y	Frame is not allowed unless there is a payable lens service code.
9Z	Lens services have been reimbursed under fitting of spectacles.
A#	Contact lens program adjustment
A*	Paper claim processing charge adjustment
A0	Paid claim twice.
A1	Doctor fees on file incorrect.
A2	Lab fees on file incorrect.
A3	Nonmember fee schedule incorrect.
A4	Adjustment.
A5	Option amount on file incorrect.
A6	Not covered under PIA. Please refer to the eManual.
A7	Redo Transaction handled privately.
A8	Health Reimbursement Arrangement indicated. Submit copy of patient’s HRA EOB.
AD	Non-covered polycarbonate option AD on safety claim
AI	Partnership Plus adjustment
B	Partnership Plus electronic auth & eClaim, $2.00 per claim.
B1	Partnership Plus electronic auth & eClaim with Altair level 1, $4.00 per claim.
B2	Partnership Plus electronic auth & eClaim with Altair level 2, $6.00 per claim.
C1	Exam has been denied. Your plan does not pay for service(s) from a non VSP Medicaid doctor in your state.
C3	Costco – Patient Paid Privately (OA Only).
C4	Under VSP redo guidelines, an addition or change in tint or coating by patient or doctor is not covered if this is the only reason for the redo.
C5	Your routine vision benefit does not cover medical vision services. The attached billed services are medical vision services.
C6	The attached claim needs to be submitted electronically in accordance with your VSP Laser VisionCareSM Program agreement.
C7	Exam processed by CIGNA Medical, COB for refraction only.
C8	The CMS-1500 claim form is not completely/accurately filled out. Please submit a new CMS-1500 claim form.
C9	Post authorization is required because of the lens type provided.
CA	The patient’s plan does not allow contact lenses unless you receive prior authorization from VSP.
CM	IOF Uncut - Combined Material Reimbursement.
CP	Paper claim charge waived.
D1	Claim or service is denied. Refer to Provider Reference Manual for appeal process.
D2	Claim or service is denied as unprocessable because it contains incomplete and/or invalid information.
D3	Claim or service is denied as unprocessable because it contains incomplete and/or invalid information and no appeal rights are afforded. Please resubmit entire claim, including attachments, with the completed/corrected information.
E	Partnership Plus electronic authorization, $0.50 per paid claim.
E1	Partnership Plus electronic authorization with Altair level 1, $1.00 per paid claim.
E4	Patient Condition Hypertension or High Cholesterol, $2.00 additional payment on Exam service.
E5	Patient Condition Diabetes or Diabetic Retinopathy, $5.00 additional payment on Exam service.
F1	Partnership Plus Frame Program, $5.00 per claim.
FQ	Elective contact lenses
G	VSP Inspire Progressive Lens, $10 per claim
HA	Payment is made at contracted rate
IF	In-Office Finishing services performed
IL	IOF Option; refer to In-Office Finishing Fee Schedule for payment
IO	Option code is not allowed with In-Office Finishing
KA	Non-covered progressive option on safety claim
KD	Non-covered polycarbonate option on safety claim
ME	Exam Payment is made at contracted rate
OM	Billed amount over the maximum allowed for this service
OP	Patient pays VSP option price for this service
P3	Patient Paid Privately (OA Only)
PC	Paper claim charge $2.00 per claim
PM	*Asterisk – VSP is unable to provide Patient Pay Materials for this plan. Please refer to the PRM for appropriate billing
PU	Patient pays doctor’s U&C fee for this service
RD	Exam payment reduced by 20% of your comp exam payable. Bill 92015 with exam service for full payment.
RX	Refraction service (92015) billed without an exam is not a payable service.
SE	Patient not eligible for this service on service date
UA	Adjustment to pay UNITY Savings.
UD	Adjustment to reverse UNITY Savings.
UF	Uncut In-Office Finishing services performed.
UI	Total UNITY Savings paid.
UN	VSP is unable to calculate patient resp. Totals exclude unknown amounts.
US	Service eligible for UNITY Savings.