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The reasons for the denial status received from the payer. Only relevant when the payer decision is denied. |
May contain organization-specific values: No |
Category Entries: |
Not Medically Necessary |
Retroactive Referral Request |
Not a Covered Benefit |
Not in Network |
Duplicate Referral Request |
System Automatically Denied |
Does Not Meet 3rd Party Guidelines |
DOES NOT MEET INTERNAL GUIDELINES |
Member not covered |
Authorized Quantity Exceeded |
Exceeds Plan Maximums |
No Prior Approval |
Requested Information Not Received |
Service Inconsistent With Diagnosis |
Pre-Existing Condition |
Patient is Restricted to Specific Provider |
Plan/Contractual Guidelines Not Followed |
Plan/Contractual Geographic Restriction |
Inappropriate Facility Type |
Once in a Lifetime Restriction Applies |
Transport Request Denied |
Errors in the Request |
Excluded Benefit |
Appeal Denied |
Not Primary Care Physician |
Level of Care Not Appropriate |
Denial Response Needs Review |
Requires Medical Review |
Experimental Service or Procedure |
Peer to Peer Needed |
Time Limits not Met |