Claim Adjustment Reason Codes are responses by payers that describe why a claim or service line was paid differently than it was billed.

Group codes are designed to assign financial responsibility for the unpaid portion of the claim balance such as CO (Contractual Obligation) assigns responsibility to the provider and PR (Patient Responsibility) assigns responsibility to the patient.

The reason codes and the messages that define those codes are used to explain why a claim may not have been paid. For instance, there are reason codes to indicate that a particular service is not covered, a benefit maximum may have been reached, or the claim lacks information required by the payer to process the claim.

There are hundreds of reason codes approved by the American National Standards Institute (ANSI) that may be used. These ANSI reason codes were designed to replace the large number of different codes used by health payers in the U.S. in an attempt to standardize the interpretation by providers in remittances.

In an effort to automate the processing and posting of these claim responses by payers the system is designed to recognize and treat different payer responses accordingly.

If payer remittances contain the following claim responses the adjustment will be posted against the service line. This will also depend on the payer level that the claim response is received from. As an example if an adjustment for a CO-45 is received and posted by a primary remittance, you wouldn't want to post another CO-45 adjustment if remitted by a secondary. The system is designed to handle this logic.

Default Claim Adjustment Rules

The following claim adjustment reason codes are configured by default in the system. You can customize this logic by editing an existing rule or creating a new custom rule.

Learn more about how to create custom claim adjustment rules
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