Section title: External Code Lists
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Provider Adjustment Reason Codes

967

These codes report payment adjustments that are not related to a specific claim, bill, or service.

Maintenance Request Status

The list below shows the status of change requests which are in process.

Each request will be in one of the following statuses:

  1. Received
    The request has been submitted but is not yet under review.
  2. Pending
    Staff has looked at the request to ensure it's a legitimate request (not spam), that it is assigned to the correct CMG, and that all required information is present.
  3. In Process
    The CMG has initiated their decision process.
  4. On Hold
    The CMG has initiated their decision process but cannot complete it at this time.
  5. CMG Approved
    The CMG has considered and approved the request, this does not mean it was approved exactly as submitted, it means maintenance related to the request was approved. Requests in this status will be applied to the next version.
  6. CMG Disapproved
    The CMG has considered and disapproved the request, no maintenance action will occur. Requests in this status are complete/final.
Status Last Reviewed: 11/1/2024
Num. Date Requested Description Type Code Status
131 12/13/2022 Domestic N95 Respirator Procurement Passthrough New CMG Approved
134 6/20/2023 Non-claims based interim payment of the provider's cost settlement amounts for Capital expense. New CMG Approved
135 6/20/2023 Non-claims based interim payment of the provider's cost settlement amount for Direct Medical Education expense. New Pending
136 6/20/2023 Non-claims based interim payment of the provider's cost settlement amount for Graduate Direct Medical Education expense. New Pending
137 6/20/2023 Non-claims based interim lump sum payment of the provider's cost settlement amount for non-Physician Anesthetists expense. New Pending
138 6/20/2023 Non-claims based interim payment of the provider's cost settlement amount for Organ Acquisition expense. New Pending
139 6/20/2023 Non-claims based interim payment of the provider's cost settlement amount for Return on Equity expense. New Pending
140 5/14/2024 A temporary allowance or settlement for an amount due to the payee which cannot be paid via normal processes. New Pending

Maintenance Request Form

Fields marked with an asterisk (*) are required

*The description you are suggesting for a new code or to replace the description for a current code.
*Explain the business scenario or use case when the requested new code would be used, the reason an existing code is no longer appropriate for the code list’s business purpose, or reason the current description needs to be revised.
11/1/2024
01Card interchange fee amount
Start: 10/01/2018
02Advanced or accelerated payment recoupment amount
Start: 03/01/2019
03Claim transmission fee amount
Start: 03/01/2019
04Real-time adjudication resulting in a payment that will follow separately.
Start: 04/11/2019
05Penalty amount withheld due to reports that were not filed
Start: 04/11/2019
06Penalty amount withheld due to reports that were filed incorrectly
Start: 04/11/2019
07Non-Internal Revenue Service third-party withholding amount unrelated to a federal payment levy program
Start: 11/01/2019
08Penalty Withholding for Bankruptcy/Termination
Start: 11/01/2019
09Domestic N95 Respirator Procurement Passthrough
Start: 11/01/2024
10Non-claims-based interim payment of the provider's cost settlement amounts for capital expense.
Start: 11/01/2024
50The amount of the late charge, late claim filing penalty, or Medicare late cost report penalty.
Start: 07/01/2018
51Late filing interest penalty assessment amount
Start: 07/01/2018 | Last Modified: 03/01/2019
72Provider refund amount
This adjustment acknowledges a refund received from a provider for previous overpayment.
Start: 07/01/2018 | Last Modified: 03/01/2019
90Early payment allowance amount
Start: 07/01/2018
AHClaim transmission fee amount
This code is used for transmission fees that are not specific to or dependent upon individual claims.
Start: 07/01/2018 | Last Modified: 03/01/2019
AMLoan repayment amount
Start: 07/01/2018 | Last Modified: 03/01/2019
APAdvanced or accelerated payment amount
Start: 07/01/2018 | Last Modified: 04/11/2019
B2Rebate amount
Applies when a provider has remitted an over payment to a health plan in excess of the amount requested by the health plan.
Start: 07/01/2018 | Last Modified: 03/01/2019
B3Recovery amount
This represents the amount received from the provider for an overpayment based on payments from other payers. This code is not used for other provider refund adjustment amounts.
Start: 07/01/2018 | Last Modified: 03/01/2019
BDBad debt amount
Start: 07/01/2018 | Last Modified: 03/01/2019
BNBonus amount
Start: 07/01/2018
CRCapitation interest amount
Start: 07/01/2018
CSAdjustment amount, detailed information is provided separately to explain the adjustment.
Start: 10/01/2018
CTCapitation payment amount
Start: 07/01/2018
E3Withholding amount
Start: 07/01/2018 | Last Modified: 03/01/2019
FBNon-claim related balance forward amount
Start: 07/01/2018 | Last Modified: 03/01/2019
FCAllocation of prepaid funds against which deductions are drawn as services are provided.
Start: 03/01/2019
FRClaim-related balance forward amount
Start: 03/01/2019
HMHemophilia clotting factor add-on payment amount
Start: 03/01/2019
IPIncentive payment amount
Start: 10/01/2018
IRInternal Revenue Service 1099 withholding amount
Start: 03/01/2019
ISLump sum based on an interim rate
Start: 04/11/2019
J1Amount not reimbursed based on a demonstration program or other limitation that prevents issuance of payment.
Start: 03/01/2019
L3Penalty amount
Start: 10/01/2018
L6Interest amount
Start: 03/01/2019
LEInternal Revenue Service non-1099 withholding amount
Start: 03/01/2019
OBAffiliated provider(s) offset amount
Start: 10/01/2018
PIPeriodic Interim Payment (PIP) lump sum amount
Start: 03/01/2019
PLFinal payment or settlement amount
Start: 10/01/2018
RARetroactive adjustment amount
Start: 10/01/2018
SLStudent loan garnishment amount
Start: 10/01/2018 | Last Modified: 03/01/2019
TLThird party liability determination amount
Start: 03/01/2019
WOOverpayment recovery amount
Start: 10/01/2018
WUNon-Internal Revenue Service withholding amount related to a federal payment levy program
Start: 11/01/2019