A denial or payment adjustment is usually explained by more than one code on the remittance advice. Read the adjustment group code, Claim Adjustment Reason Code, and any Remittance Advice Remark Codes together.
Common adjustment groups
- CO: Contractual obligation.
- PR: Patient responsibility.
- OA: Other adjustment.
- PI: Payer-initiated reduction.
A practical review process
- Confirm the patient, member ID, dates of service, and payer.
- Match the reason and remark codes to the affected service line.
- Compare the claim with the payer’s policy, authorization, eligibility, coding, and filing rules.
- Correct and resubmit only when the payer permits it; otherwise use the payer’s reconsideration or appeal process.
Do not rely on a brief code description alone. The same code can require a different action depending on the payer, contract, service, and accompanying remarks.
Billing reminder: Payer and program requirements vary. Confirm the current instructions for the payer receiving the claim.