Look up a Medicare reason code

Medicare reason codes are 3-digit codes used in processing reports and in the Medicare statement of benefits.

These codes provide information about how a claim was assessed.

You can download the Medicare 3-digit reason codes into your practice software.

Use the filter box. Enter the code or keywords from the reason code message. 

CodeDescription
101More details of service required to assess benefit.
102No amount charged is shown on invoice/receipt.
103Letter of explanation is being sent separately.
104Balance of benefit due to claimant.
105Benefit paid to provider as requested.
106Servicing provider unable to be identified.
107Benefit paid on item number other than that claimed.
108Benefit is not payable for the service claimed.
111No benefit payable - service over 2 years old.
113Total charge shown on invoice apportioned over all items.
115Benefit recommended for this item.
117Benefit not recommended for this item.
120Age restriction applies to this item.
122Associated referral/request line not required.
123Benefit paid on radiology item other than service claimed.
124Item is restricted to persons of opposite sex to patient.
125Not payable without associated operation/anaesthetic item.
126Service is not payable without radiology service.
127Maximum number of additional fields already paid.
128Benefit paid on associated fracture/amputation item.
129Service is not payable without associated base item.
130Letter of explanation is being sent separately.
131Date of service not supplied/invalid.
134Single course of treatment paid as subsequent attendance.
135Provider not a consultant physician - specialist rate paid.
136Referral details not supplied - paid at gp rate.
137Details of requesting provider not shown on invoice/receipt.
138Benefit only payable when self-determined/deemed necessary.
139Approved pathologist should not use this item number.
140Non-specialist provider.
141No benefit payable for services performed by this provider.
142Letter of explanation is being sent separately.
144Claim benefit not paid - further assessment required.
150Member has not supplied details to permit claim payment.
151Associated service already paid - adjustment being processed.
154Diagnostic imaging multiple service rule applied to service.
155Letter of explanation is being sent separately.
157Service possibly aftercare - refer to provider.
158Benefit paid on associated abandoned surgery/anae item.
159Item associated with other service on which benefit payable.
160Maximum number of services for this item already paid.
161Adjustment to benefit previously paid.
162Benefit has been previously paid for this service.
163Surgical/anaesthetic item/s already paid for this date.
164Assistant surgeon benefit not payable.
166Letter of explanation is being sent separately.
168Not payable without associated operation/anaesthetic item.
169Operation/anaesthetic item not claimed.
170Assistant anaesthetic benefit not payable.
171Benefit not payable - provider may only act in one capacity.
173Patient episode coning - maximum number of services paid.
174Patient episode coning adjustment.
175Benefit paid on associated foetal intervention item.
176Pay each foetal intervention item as a separate item.
177Foetal intervention item paid using derived fee item.
179Benefit not payable - associated service already paid.
184Benefit paid for additional time item using a derived fee.
194Letter of explanation is being sent separately.
195Letter of explanation is being sent separately.
206Item number does not attract a benefit at date of service.
208Card number used has expired.
209Claimants name stated is different to that on card number.
211Patient not covered by this card number at date of service.
212Date of service used is in the future.
214Claim form not complete.
215Service claimed prior to 1 february 1984.
217Patient cannot be identified from information supplied.
222Benefit paid on associated anaesthetic item.
223Service not payable - specified item not claimed or present.
225Patient contribution substantiated - additional benefit paid.
226Date of service is prior to patient’s date of birth.
227Date of service prior to date eligible for medicare benefit.
228Date of service after benefit period for overseas visitor.
229Benefit paid at 100% of schedule fee.
230Combination of 85% and 100% of schedule fee paid.
232Service claimed not covered by medicare.
233Provider not entitled to benefit at date of service.
234Letter of explanation is being sent separately.
236Letter of explanation is being sent separately.
237Letter of explanation is being sent separately.
238Not paid because all associated services rejected.
240Gap adjustment to benefit previously paid.
241Total charge and benefit for multiple procedure.
242Service is part of a multiple procedure.
243Apportioned charge and total benefit for multiple procedure.
244Benefit not paid - service line in error.
245Benefit paid on service other than that claimed.
246Patient cannot be identified from information supplied.
250Explanation/voucher will be forwarded separately.
251Details of requesting provider not supplied.
252Service possibly aftercare.
253Radiotherapy assessed with other item number in claim.
254Assessment incomplete - further advice will follow.
255Benefit assigned has been increased.
256Item cannot be claimed as an in-hospital service.
260Benefit assessed with associated item on statement.
261Associated surgical items/anaesthetic time not supplied.
262Insufficient prolonged anaesthetic time - service not paid.
264Benefit not payable - compensation/damages service.
265Service not covered by reciprocal health care agreement.
267Service not payable - associated service not present.
271Not payable without associated ophthalmological item.
272Benefit paid on associated ophthalmological item.
274Provisional payment.
280Cannot identify service - resubmit with correct mbs item.
282Date of service outside of referral/request period.
306Card not valid at date of service - future claims may reject.
307Claim not paid - card number not valid at date of service.
308Ivf service - conditions not met - no benefit payable.
316Benefit not payable - item cannot be self-determined.
317Benefit not payable - additional item to those requested.
320Quoted medicare card number is incorrect.
322Provider not approved for this medicare pathology benefit.
325Laboratory not accredited for benefits for this service.
326Laboratory not accredited for benefits at date of service.
328Benefit paid on associated tomography item.
329Not payable without associated tomography item.
331Benefit not payable – h.i.act sect 20(a)(1).
332Category 5 lab - benefit not payable for requested service.
333Provider must claim time-based items.
334Benefit not payable - associated pathology must be inpatient.
335Service is not payable without nuclear medicine service.
336Benefit paid on nuclear medicine item other than one claimed.
337Provider must claim content-based items.
338Provider not registered to claim benefit at date of service.
339Benefit paid at the concession rate.
340Refund of co-payment amount.
341No referral details - details required for future claims.
342Referral expired - paid at unreferred (gp) rate.
343Card number quoted for this claim has been cancelled.
344Concession number invalid - benefit paid at general rate.
345No safety net entitlement - benefit paid at general rate.
346Co-payment not made - $2.50 credited to threshold.
347Safety net threshold reached - benefit increased.
348Overpayment of claim - invalid concession number.
349Replacement for requested eft payment rejected by bank.
350Hospital referral - paid at specialist/consultant rate.
351Benefit not payable - lcc number incorrect or not supplied.
352Service date outside lcc registration dates.
353Pathology items not present - no benefit payable.
356Documentation required to process service.
358Documentation not received - unable to process service.
359Documentation not received - unable to process claim.
360No benefit payable when requested by this provider.
361Di exemption - items not approved.
364Items must be claimed as a combination item.
367Service associated with mbac item in a multiple procedure.
370Benefit paid on item number other than that claimed.
371Future claims quoting old style card no will be rejected.
372Old style card number quoted - benefit not payable.
373Expired card - benefit not payable.
374Old card issue used - benefit not payable - also refer @.
375Service being processed manually.
377Number of patients seen not indicated.
378Provider cannot refer/request service at date of request.
390Documentation not received.
391Service provider on db1 differs from transmitted data.
392Benefit amount changed.
393No benefit payable - baby not an admitted inpatient.
395Tac medical excess.
400Equipment number missing or invalid.
401Benefit not payable - charge amount missing or invalid.
402Benefit not payable - number of patients attended required.
403Subsequent consultation - referral details required.
404Benefit not payable - referral/request details required.
405Equipment number invalid for servicing provider.
406Supporting text required to assess claim.
407Benefit not payable - overseas student.
408Date of service prior to 29 may 1995.
409Card number for this enrolment needs to be verified.
410Age restriction applies for this item - verify details.
411Mbac determination/precedent number not supplied or invalid.
412Benefit not payable - provider unable to claim this service.
413Benefit not payable - date of serv prior to date of request.
414Provider practice location is closed at date of service.
415Referral details same as rendering provider - self-deemed?
416Services form a composite item - composite item required.
417Referral needed - if no referral, nr item to be transmitted.
418Item cannot be claimed more than once in one attendance.
419Benefit already paid on item - verify if multiple pregnancy.
420Operation/s schedule fee does not meet item description.
421Wrong assistant item used for the operation/s performed.
422Benefit paid has been reduced (benefit = charge).
423Optical condition not specified - no benefit payable.
424More information required - which eye was treated.
425Benefit not payable - individual charges required.
426Indicate whether new treatment or continuing management.
427Compensation related services - please forward documents.
428Date of service over 2 years - late lodgement form required.
429Patient cannot be identified from the information supplied.
430Conflicting referral details - please clarify.
431Initial consultation previously paid - query subsequent con.
432Not multi-op - more information required to pay benefit.
433Associated referral/request line not required.
434Expired or invalid card - benefit not payable.
435Service for nursing home care recipient - benefit not paid.
436Cannot claim out of hospital service through simp bill.
437Card details invalid - a new medicare number has been issued.
438Consultation and di item/s not payable on same day.
439Referring/requesting provider not in eligible area.
440Multiple echocardiogram services rule applied.
441Multiple echocardiogram and di services rules applied.
442Patient not mymedicare registered with provider/practice.
443Patient mymedicare registered with another provider/practice.
444Required eligible base item not present in the same claim.
445Benefit paid on associated base item.
446Total benefit for plastic and reconstructive procedure paid.
449Held eft payment reprocessed - incorrect claimant selected.
450Eft details invalid - cheque issued for benefit.
451Service provided in an ineligible location.
452Resubmit claim for this service - image not claim related.
453Resubmit claim for service - claim details do not match image.
454Resubmit claim for service - some details not shown on image.
455Resubmit claim for this service - include account and receipt.
456No action required - line adjusted to process claim.
457No action required - line adjusted to process claim.
458No action required - benefit paid on adjusted claim.
461Adjustment to benefit previously paid.
475Patient/service details invalid or missing.
500Rejected in association with another item in this claim.
501Group attendance or item format invalid.
502Patient is not eligible to claim benefit for this item.
503Referral date format is invalid.
504Charge amount missing/invalid - no benefit payable.
505More information required - evidence of condition.
506Consultation not payable on same day as surgical procedure.
507Site not accredited for this service.
509Service paid as item 2712/2719.
510Service paid as item 52-96 or similar item.
511Emsn threshold reached - cap applied to benefit.
512Multiple musculoskeletal mri service rule applied.
513Multiple musculoskeletal mri and di services rules applied.
514Required equipment type code not on lspn register.
515Equipment is older than allowable age for this item.
516Benefit paid for base and derived radiotherapy items.
517Mpsn threshold reached - 80% out of pocket paid.
518Benefit paid at 100% schedule fee + emsn.
519Mpsn threshold reached - partial 80% out of pocket paid.
520Benefit paid at 100% schedule fee + part 80% out of pocket.
521Paid part 80% out of pocket + between 85% and 100% increase.
522Benefit paid - emsn + between 85% and 100% schedule fee.
524Safety net benefit adjusted.
525Only attracts benefit when claimed via bulk bill.
528Provider not in eligible area (incorrect rrma/ssd or state).
529Bulk bill additional payment item claimed incorrectly.
530Patient not on concession/under 16 years at date of service.
535Missing data.
536Location specific practice number not supplied.
537Location specific practice number invalid.
538Location specific practice number not recognised.
539Location specific practice num not valid at date of service.
540Enhanced primary care plan item not previously paid.
549Bulk bill incentive item already paid - adjustment required.
550Associated service not claimed - no benefit payable.
551Specimen collection point is incorrect or not supplied.
552Specimen collection point not valid at date of service.
553Approved collection centre number not supplied.
554Total benefit for anaesthetic service.
555Benefit paid on main rvg anaesthetic item.
556Rvg time item not claimed.
557Associated rvg anaesthetic service not claimed.
558Rvg anaesthetic item not claimed.
559Patient outside age range - please verify age.
560Rvg item restriction.
561Benefit paid on rvg item claimed.
562Benefit paid on associated rvg anaesthetic item.
563Associated rvg service already paid.
564Multiple vascular ultrasound services site rule applied.
565Multiple di and vascular ultrasound service rules applied.
566Total benefit for diagnostic imaging service.
567Benefit paid on main diagnostic imaging item.
568Item cannot be substituted.
569Provider unable to substitute.
600Requesting/referring provider unable to be identified.
601In-hospital services cannot be claimed as out-of-hospital.
602Out-of-hospital service cannot be claimed as in-hospital.
603Newborn not yet enrolled with medicare - no benefit payable.
604Service over 6 months old - late lodgement form required.
605Referral expired - no benefit payable.
606Referring provider number not open at date of referral.
607Referral date/period omitted or unable to be determined.
608Referring and servicing provider same - no benefit payable.
609Service/claim cancelled at provider’s request.
610Provider specialty not consistent with item claimed.
611Referral/request details not supplied - no benefit payable.
612Date of referral after date of service - no benefit payable.
613Card number cannot be identified from information supplied.
614No benefit payable - please notate time of each visit.
615Multiple procedures - notate times and area of treatment.
616Item cannot be claimed as an in-hospital service.
617Item cannot be claimed as an out-of-hospital service.
618No benefit if requested by this provider at date of request.
619Servicing provider number not open at date of service.
620Duplicate transmission - no further payment made.
621Item not claimable electronically.
622Pet drop-down items not claimable via edi.
623Pet items only claimable via direct bill.
624Pet items - payee provider required.
625Payee provider not eligible to claim pet items.
627Pdt statement not provided by the doctor.
629Initial pdt therapy item not present on patient history.
633Refer back to the specialist (referring provider is closed).
634Refer back to the specialist (servicing provider is closed).
635Late lodgement not approved - letter being sent separately.
636Benefit reduced - dental cap broken.
637No benefit payable - dental cap reached.
638Derived fee and other item cannot be claimed in-hospital.
639Provider not in an eligible area to claim this item.
640More than one base and derived item claimed.
641More than one base item claimed.
642Benefit paid for derived and other item claimed.
643Derived item assessed with other item on statement.
700Benefit cannot be determined for this service.
701Benefit cannot be determined due to complex assessing rules.
702Item restrictive with another item.
703Duplicate of item already quoted.
704Provider not permitted to claim this item.
705No associated pathology service.
706Provider not associated with a pathology laboratory.
707Pathology laboratory not registered at date of service.
708Item cannot be claimed from this pathology laboratory.
709Another assistant item should be claimed.
710Associated surgical items not present.
711Unable to determine associated surgery.
712Base item not present or in incorrect order.
713Radiotherapy fields greater than maximum allowable.
714Benefit not determined - number ot time units not present.
715Number of time units exceeded maximum allowable.
716Service forms a composite item - composite item required.
717Benefit not payable on this service for a hospital patient.
718Provider location not open at date of service.
719Benefit cannot be calculated for hyperbaric oxygen therapy.
720Eligibility cannot be determined for this item.
732Referral period not valid for referring provider.
Page last updated: 15 June 2024.
QC 74046