Deductible Amount

This portion of your bill is being applied to your annual deductible. You owe this amount until your deductible is met for the year.

Coinsurance Amount

After your deductible is met, you still owe a percentage of each claim — this is your coinsurance share.

Copay Amount

A fixed dollar amount you owe for this visit or service as defined by your plan.

The service/equipment is not covered

Your insurance plan does not cover this specific service, item, or procedure at all.

The service/treatment is not authorized

Your insurer says no prior authorization was obtained for this service before it was performed.

The procedure/revenue code is inconsistent with the modifier

A billing code modifier doesn't match the procedure code, causing the claim to be adjusted or denied.

The procedure code is inconsistent with the place of service

The billed procedure doesn't match the type of facility or location where the service was performed.

The procedure code is inconsistent with the provider type

The billed service doesn't match the type of provider who performed it according to their license or specialty.

The diagnosis is inconsistent with the procedure

The diagnosis code on the claim doesn't medically support the procedure that was billed.

The diagnosis is inconsistent with the patient's age

The billed diagnosis doesn't match the patient's age — for example, a pediatric condition billed for an adult.

The diagnosis is inconsistent with the patient's gender

The billed diagnosis doesn't match the gender on file for the patient.

The diagnosis is inconsistent with the admission type

The diagnosis doesn't match how the admission was categorized (e.g., elective vs. emergency).

Payment adjusted because the submitted authorization number is missing, invalid, or does not apply

The prior authorization number on the claim is missing, wrong, or doesn't match what the insurer has on file.

Claim/service lacks information or has submission/billing error(s)

The claim is missing required information or contains errors that prevent processing.

Duplicate claim/service

Your insurer flagged this claim as a duplicate of one already processed.

Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier

The insurer says this injury or illness should be covered by workers' compensation, not your health plan.

This care may be covered by another payer per coordination of benefits

Your insurer thinks another insurance plan — like a spouse's plan — should pay first.

The impact of prior payer(s) adjudication including payments and/or adjustments

The payment reflects what's left after another insurer already paid part of this claim.

Charges are covered under a capitation agreement/contract

Your provider is paid a fixed monthly rate for your care, so no additional fee-for-service payment is made.

Expenses incurred prior to coverage

The service was performed before your insurance coverage was active.

Expenses incurred after coverage terminated

Your insurance had already ended when this service was performed.

The time limit for filing has expired

The claim was not submitted to the insurer within the required filing deadline.

Patient cannot be identified as our insured

The insurer can't match the patient to an active member record.

Our records indicate that this dependent is not an eligible dependent as defined

The person receiving care doesn't qualify as a dependent under the plan's rules.

Lifetime benefit maximum has been reached

Your plan's lifetime coverage cap for this type of service has been exhausted.

Charge exceeds fee schedule/maximum allowable

The provider billed more than the contracted or allowed rate. You're only responsible for your share of the allowed amount — not the billed amount.

This (these) diagnosis(es) is (are) not covered, missing, or are invalid

The diagnosis code on the claim is missing, invalid, or not covered by your plan.

These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam

Your insurer is treating this service as part of a routine exam rather than a medically necessary visit.

These are non-covered services because this is not deemed a 'medical necessity' by the payer

Your insurer decided this service wasn't medically necessary, so they won't pay for it.

These are non-covered services because this is a pre-existing condition

The insurer is denying this claim because your condition existed before your coverage started.

Procedures or services are not compatible with this type of service

The billed procedure can't be performed or billed alongside another procedure that was already paid.

Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service

The location where this service was performed isn't appropriate for this type of care per your insurer.

Processed based on multiple or concurrent procedure rules

When multiple procedures are performed at the same time, the payment for secondary procedures is reduced.

Predetermination: anticipated payment upon completion of services or claim adjudication

This EOB is a pre-determination of what your insurance would pay — not a final claim decision.

The related or qualifying claim/service was not identified on this claim

A required reference to a related claim (like a referring provider or parent claim) is missing.

Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

You submitted the claim to the wrong insurance company.

Benefit maximum for this time period or occurrence has been reached

You've used all the allowed visits, days, or dollar amount for this type of benefit this year.

Submission/billing error(s). At least one Remark Code must accompany this code.

There's a billing or submission error — the remark code on the same line explains the specific issue.

The disposition of this claim/service is pending further review

Your insurer hasn't made a final decision yet — the claim is still under review.

Patient/insured health identification number and name do not match

The name and insurance ID number on the claim don't match what's in the insurer's system.

Payment adjusted because the payer deems the information submitted does not support this many/frequency of services

Your insurer says the number or frequency of services billed doesn't seem clinically reasonable based on the information submitted.

Payment is denied when performed/billed by this type of provider

This service isn't covered when performed by the type of provider who billed it.

Payment denied for absence of, or exceeded, precertification/authorization

Prior authorization wasn't obtained, or the service went beyond what was authorized.

Services not related to the specific accident/illness

The service doesn't appear to be connected to the injury or illness for which you're being treated under a specific claim or benefit.

Do not resubmit; we will reprocess this claim after the contract is finalized

Your insurer is asking you to wait — the provider's contract is being resolved and the claim will be reprocessed automatically.

Non-standard adjustment code from paper remittance

This adjustment was made based on information from a paper (non-electronic) process and doesn't have a standard code.

Precertification/authorization/notification/pre-treatment absent

Required advance approval wasn't obtained before this service was performed.

Expenses incurred during lapse in coverage

Coverage had lapsed at the time the service was performed — usually due to a missed premium.

Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete

The insurer asked the provider for more information but didn't get it in time.

An attachment/other documentation is required to adjudicate this claim/service

Your insurer needs additional documents from the provider to process this claim.

Sequencing of therapy and/or diagnostic treatment is incorrect

Your insurer says the order in which treatments were tried doesn't follow their required clinical pathway.

This provider was not certified/eligible to be paid for this procedure/service on this date of service

The provider who performed this service wasn't credentialed or eligible to bill for it on the date of your visit.

Services not covered because the patient is enrolled in a Hospice program

If a patient is in hospice, most curative treatments are no longer covered by Medicare or the plan.

Non-covered charge(s). At least one Remark Code must accompany this code.

This charge is not covered, and the accompanying remark code explains why.

The benefit for this service is included in the payment/allowance for another service/procedure

This charge was bundled into a payment that already covered another related service.

Payment made to patient/insured/responsible party

The insurance payment was sent directly to you instead of to the provider.

Contracted/negotiated rate expired or not on file

The provider's contract with the insurer is outdated or missing, so the normal in-network rate doesn't apply.

This service/equipment/drug is not covered under the patient's current benefit plan

The specific service, device, or drug isn't included in your current plan's covered benefits.

This procedure is not paid separately

This procedure's payment is included in a bundled payment for the overall service.

Alert: You may appeal this decision

You have the right to file a formal appeal of this payment decision.

Patient ineligible for this service

The patient doesn't meet the eligibility requirements for this specific service.

This decision was based on a Local Coverage Determination (LCD)

A Medicare local policy in your geographic area was used to decide whether to cover this service.

Consult plan benefit documents/summary plan description for further information

Check your plan documents for the specific rule that caused this adjustment.

Resubmit a separate claim for this service

This service needs to be billed on its own separate claim — it can't be included with the current one.

If you do not agree with what we approved for these services, you may appeal our decision

You can formally challenge the payment amount or denial decision.

Secondary payment cannot be considered without the identity of or payment information from the primary payer

The secondary insurer can't process this until they get the primary insurer's payment information.

Alert: This claim has been forwarded to the patient's additional plan

Your insurer has automatically sent this claim to your secondary insurance for additional processing.

Missing/incomplete/invalid social security number or health insurance claim number

The patient's Social Security Number or Medicare claim number on the form is missing or incorrect.

Alert: This claim has been split for processing

Your insurer divided this claim into multiple parts for processing.