Claim Medicare Non Payment Reason Code
The reason that no Medicare payment is made for services on an institutional claim.
This field was put on all institutional claim types but data did not start coming in on OP/HHA/Hospice until 4/1/02. Prior to 4/1/02, data only came in Inpatient/SNF claims.
Effective 4/1/02, this field was also expanded to two bytes to accommodate new values.
The NCH Nearline file did not expand the current 1-byte field but instituted a crosswalk of the 2-byte field to the 1-byte character value. See table of code for the crosswalk.
NOTE3: Effective with Version 'J', the field has been expanded on the NCH claim to 2 bytes. With this expansion the NCH will no longer use the character values to represent the official two byte values being sent in by NCH since 4/2002.
During the Version 'J' conversion, all character values were converted to the two byte values.
This variable is coded, and will contain one of the following values.
| Value | Description |
|---|---|
A |
Covered worker's compensation (Obsolete) |
B |
Benefit exhausted |
C |
Custodial care – non-covered care (includes all 'beneficiary at fault' waiver cases) (Obsolete) |
E |
HMO out-of-plan services not emergency or urgently needed (Obsolete) |
E |
MSP cost avoided - IRS/SSA/HCFA Data Match (eff. 7/00) |
F |
MSP cost avoid HMO Rate Cell (eff. 7/00) |
G |
MSP cost avoided Litigation Settlement (eff. 7/00) |
H |
MSP cost avoided Employer Voluntary Reporting (eff. 7/00) |
J |
MSP cost avoid Insurer Voluntary Reporting (eff. 7/00) |
K |
MSP cost avoid Initial Enrollment Questionnaire (eff. 7/00) |
N |
All other reasons for non-payment |
P |
Payment requested |
Q |
MSP cost avoided Voluntary Agreement (eff. 7/00) |
R |
Benefits refused, or evidence not submitted |
T |
MSP cost avoided - IEQ contractor (eff. 9/76) (obsolete 6/30/00) |
U |
MSP cost avoided - HMO rate cell adjustment (eff. 9/76) (Obsolete 6/30/00) |
V |
MSP cost avoided - litigation settlement (eff. 9/76) (Obsolete 6/30/00) |
W |
Worker's compensation (Obsolete) |
X |
MSP cost avoided - generic |
Y |
MSP cost avoided - IRS/SSA data match project (obsolete 6/30/00) |
Z |
Zero reimbursement RAPs -- zero reimbursement made due to medical review intervention or where provider specific zero payment has been determined. (effective with HHPPS - 10/00) |
00 |
MSP cost avoided - COB Contractor |
12 |
MSP cost avoided - BCBS Voluntary Agreements |
13 |
MSP cost avoided - Office of Personnel Management |
14 |
MSP cost avoided - Workman's Compensation (WC) Datamatch |
15 |
MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) (eff. 4/2006) |
16 |
MSP cost avoided - Liability Insurer VDSA (eff. 4/2006) |
17 |
MSP cost avoided - No-Fault Insurer VDSA (eff. 4/2006) |
18 |
MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement (eff. 4/2006) |
19 |
SEE NOTE4: Coordination of Benefits Contractor 11119 (see CMS Change Request 7906 for identification of the contractor.) |
21 |
MSP cost avoided - MIR Group Health Plan (eff. 1/2009) |
22 |
MSP cost avoided - MIR non-Group Health Plan (eff. 1/2009) |
25 |
MSP cost avoided - Recovery Audit Contractor - California (eff. 10/2005) |
26 |
MSP cost avoided - Recovery Audit Contractor - Florida (eff. 10/2005) |
42 |
SEE NOTE4: Coordination of Benefits Contractor 11142 (see CMS Change Request 7906 for identification of the contractor.) |
43 |
SEE NOTE4: Coordination of Benefits Contractor 11143 (see CMS Change Request 7906 for identification of the contractor.) Effective 4/1/02, the Medicare nonpayment reason code was expanded to a 2-byte field. The NCH instituted a crosswalk from the 2-byte code to a 1-byte character code. Below are the character codes (found in NCH & NMUD). At some point, NMUD will carry the 2-byte code but NCH will continue to have the 1-byte character code. |
! |
MSP cost avoided - COB Contractor ('00' 2-byte code) |
@ |
MSP cost avoided - BC/BS Voluntary Agreements ('12' 2-byte code) |
# |
MSP cost avoided - Office of Personnel Management ('13' 2-byte code) |
$ |
MSP cost avoided - Workman's Compensation (WC) Datamatch ('14' 2-byte code) |
* |
MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) ('15' 2-byte code) (eff. 4/2006) |
( |
MSP cost avoided - Liability Insurer VDSA ('16' 2-byte code) (eff. 4/2006) |
) |
MSP cost avoided - No-Fault Insurer VDSA ('17' 2-byte code) (eff. 4/2006) |
+ |
MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement ('18' 2-byte code) (eff. 4/2006) |
< |
MSP cost avoided - MIR Group Health Plan ('21' 2-byte code) (eff. 1/2009) |
> |
MSP cost avoided - MIR non-Group Health Plan ('22' 2-byte code) (eff. 1/2009) |
% |
MSP cost avoided - Recovery Audit Contractor - California ('25' 2-byte code) (eff. 10/2005) |
& |
MSP cost avoided - Recovery Audit Contractor - Florida ('26' 2-byte code) (eff. 10/2005) |
Some additional information on this variable: