Medicare reason codes
The following is a list of explanation codes currently in use by Medicare Programs. These codes describe what has happened during assessing of a claim for Medicare benefits. These codes are accompanied by a brief explanation of what the code means. If you require further clarification of these codes, please phone 132 011 (general public), or 132 150 (providers only).
Where an @ symbol appears on a statement of benefits it means the card number quoted on the claim has been changed to reflect the current card issue number.
Download Medicare reason codes
The Medicare Reason codes can be downloaded for use in your programs. Reason codes are availalable in a CSV (Comma Separated Values) format. The file is compressed in ZIP format. There are many tools which can be used for manipulating ZIP files such as Alladin Expander free for Microsoft Windows and Apple Macintosh, and non-free (Alladin Stuffit) for Linux and Sun Solaris. WinZip (for Microsoft Windows), currently a shareware product. InfoZip (for many platforms).
The ZIP contains one file, a CSV file, which is a variable width record. This is a file format which can be opened by a number of products on personal computers, including Microsoft Excel. The file format is "numeric","text" where: numeric = reason code number, text = short descriptive text. No column headings are included.
Browse Medicare reason codes
| 101 | More details of service required to assess benefit |
| 102 | No amount charged is shown on voucher |
| 103 | Letter of explanation is being sent separately |
| 104 | Balance of benefit due to claimant |
| 105 | Benefit paid to provider as requested |
| 106 | Servicing provider unable to be identified |
| 107 | Benefit paid on item number other than that claimed |
| 108 | Benefit is not payable for the service claimed |
| 110 | Benefit paid details verified with provider/claimant |
| 111 | No benefit payable - claims/s over 2 years old |
| 113 | Total charge shown on account apportioned over all items |
| 115 | Benefit recommended for this item |
| 117 | Benefit not recommended for this item |
| 120 | Age restriction applies to this item |
| 122 | Associated referral/request line not required |
| 123 | Benefit paid on radiology item other than service claimed |
| 124 | Item is restricted to persons of opposite sex to patient |
| 125 | Not payable without associated operation/anaesthetic item |
| 126 | Service is not payable without radiology service |
| 127 | Maximum number of additional fields already paid |
| 128 | Benefit paid on associated fracture/amputation item |
| 129 | Service is not payable without the base item/s |
| 130 | Referred to National Office for decision |
| 131 | Date of service not supplied/invalid |
| 134 | Single course of treatment paid as subsequent attendance |
| 135 | Provider not a consultant physician - specialist rate paid |
| 136 | Referral details not supplied- paid at GP rate |
| 137 | Details of requesting provider not shown on account/receipt |
| 138 | Benefit only payable when self-determined/deemed necessary |
| 139 | Approved pathologist should not use this item number |
| 140 | Non-specialist provider |
| 141 | No benefit payable for services performed by this provider |
| 142 | Letter of explanation is being sent separately |
| 144 | Claim benefit not paid - further assessment required |
| 150 | Member has not supplied details to permit claim payment |
| 151 | Associated service already paid-adjustment being processed |
| 154 | Diagnostic Imaging Multiple Service Rule applied to service |
| 155 | Letter of explanation is being sent separately |
| 157 | Service possibly aftercare - refer to provider |
| 158 | Benefit paid on associated abandoned surgery/anae item |
| 159 | Item associated with other service on which benefit payable |
| 160 | Maximum number of services for this item already paid |
| 161 | Adjustment to benefit previously paid |
| 162 | Benefit has been previously paid for this service |
| 163 | Surgical/anaesthetic item/s already paid for this date |
| 164 | Assistant surgeon benefit not payable |
| 166 | Letter of explanation is being sent separately |
| 168 | Not payable without associated operation/anaesthetic item |
| 169 | Operation/anaesthetic item not claimed |
| 170 | Assistant anaesthetic benefit not payable |
| 171 | Benefit not payable - provider may only act in one capacity |
| 173 | Patient episode coning - maximum number of services paid |
| 174 | Patient episode coning adjustment |
| 175 | Benefit paid on associated foetal intervention item |
| 176 | Pay each foetal intervention item as a separate item |
| 177 | Foetal intervention item paid using derived fee item |
| 179 | Benefit not payable - associated service already paid |
| 184 | Benefit paid for additional time item using a derived fee |
| 194 | Letter of explanation is being sent separately |
| 195 | Letter of explanation is being sent separately |
| 206 | Item number does not attract a benefit at date of service |
| 208 | Card number used has expired |
| 209 | Claimants name stated is different to that on card number |
| 211 | Patient not covered by this card number at date of service |
| 212 | Date of service used is in the future |
| 214 | Claim form not complete |
| 215 | Service claimed prior 1 February 1984 |
| 217 | Patient cannot be identified from information supplied |
| 222 | Benefit paid on associated anaesthetic item |
| 223 | Service not payable - specified item not claimed or present |
| 225 | Patient contribution substantiated-additional benefit paid |
| 226 | Date of service is prior to patients date of birth |
| 227 | Date of service prior to date eligible for Medicare benefit |
| 228 | Date of service after benefit period for overseas visitor |
| 229 | Benefit paid at 100% of schedule fee |
| 230 | Combination of 85% and 100% of schedule fee paid |
| 232 | Service claimed not covered by Medicare |
| 233 | Provider not entitled to Medicare benefit at date of service |
| 234 | Letter of explanation is being sent separately |
| 236 | Letter of explanation is being sent separately |
| 237 | Letter of explanation is being sent separately |
| 238 | Not paid because all associated services rejected |
| 240 | Gap adjustment to benefit previously paid |
| 241 | Total charge and benefit for multiple procedure |
| 242 | Service is part of a multiple procedure |
| 243 | Apportioned charge and total benefit for multiple procedure |
| 244 | Benefit not paid - service line in error |
| 245 | Benefit paid on service other than that claimed |
| 246 | Patient cannot be identified from information supplied |
| 250 | Explanation/voucher will be forwarded separately |
| 251 | Details of requesting provider not supplied |
| 252 | Service possibly aftercare |
| 253 | Radiotherapy assessed with other item number on statement |
| 254 | Assessment incomplete - further advice will follow |
| 255 | Benefit assigned has been increased |
| 256 | Benefit not payable on this service for a hospital patient |
| 260 | Benefit assessed with associated item on statement |
| 261 | Associated surgical items/anaesthetic time not supplied |
| 262 | Insufficient prolonged anaesthetic time - service not paid |
| 264 | Benefit not payable - compensation/damages service |
| 265 | Service not covered by reciprocal health care agreement |
| 267 | Service not payable - associated service not present |
| 271 | Not payable without associated ophthalmological item |
| 272 | Benefit paid on associated ophthalmological item |
| 274 | Provisional payment |
| 280 | Cannot identify service. resubmit with correct MBS item |
| 306 | Card# not valid at date of service-future claims may reject |
| 307 | Claim not paid card number not valid for date of service |
| 308 | IVF service - conditions not met - no benefit payable |
| 316 | Benefit not payable - item cannot be self-determined |
| 317 | Benefit not payable - additional item to those requested |
| 320 | Quoted Medicare card number is incorrect |
| 322 | Provider not approved for this Medicare pathology benefit |
| 325 | Laboratory not accredited for benefits for this service |
| 326 | Laboratory not accredited for benefits at date of service |
| 328 | Benefit paid on associated tomography item |
| 329 | Not payable without associated tomography item |
| 331 | Benefit not payable - HI act sect 20(a)(1) |
| 332 | Category 5 lab - benefit not payable for requested service |
| 333 | Provider must claim time-based items |
| 334 | Benefit not payable-associated pathology must be inpatient |
| 335 | Service is not payable without nuclear medicine service |
| 336 | Benefit paid on nuclear medicine item other than one claimed |
| 337 | Provider must claim content-based items |
| 338 | Provider not registered to claim at date of service |
| 339 | Benefit paid at the concession rate |
| 340 | Refund of co-payment amount |
| 341 | No referral details - details required for future claims |
| 342 | Referral expired - paid at un-referred (GP) rate |
| 343 | Card number quoted on claim form has been cancelled |
| 344 | Concession number invalid - benefit paid at general rate |
| 345 | No safety net entitlement - benefit paid at general rate |
| 346 | Co-payment not made - $2.50 credited to threshold |
| 347 | Safety net threshold reached - benefit increased |
| 348 | Overpayment of claim - invalid concession number |
| 349 | Replacement for requested EFT payment rejected by bank |
| 350 | Hospital referral - paid at specialist/consultant rate |
| 351 | Benefit not payable - LCC number incorrect or not supplied |
| 352 | Service date outside LCC registration dates |
| 353 | Pathology items not present - no benefit payable |
| 356 | Documentation required to process service |
| 359 | Documentation not received - unable to process claim |
| 360 | No benefit payable when requested by this provider |
| 361 | DI exemption/items not approved |
| 364 | Items claimed must be as a combination item |
| 367 | Service associated with MBAC item in a multiple procedure |
| 370 | Benefit paid on item number other than that claimed |
| 371 | Future claims quoting old style card no. will be rejected |
| 372 | Old style card number quoted - benefit not payable |
| 373 | Expired card - benefit not payable |
| 374 | Old card issue used - benefit not payable - also refer @ |
| 375 | Service being processed manually |
| 377 | Number of patients seen not indicated |
| 378 | Provider cannot refer/request service at date of request |
| 390 | Documentation not received |
| 391 | Service provider on db1 differs from transmitted data |
| 392 | Benefit amount changed |
| 393 | No benefit payable - baby not an admitted inpatient |
| 395 | TAC medical excess |
| 397 | Services not related to current compensation case |
| 400 | Equipment number missing or invalid |
| 401 | Benefit not payable - charge amount missing or invalid |
| 402 | Benefit not payable- number of patients attended required |
| 403 | Subsequent consultation - referral details required |
| 404 | Benefit not payable - referral/request details required |
| 405 | Equipment number invalid for servicing provider |
| 406 | Unable to assess claim - please forward documents |
| 407 | Benefit not payable - overseas student |
| 408 | Date of service prior to 29 May 1995 |
| 409 | Card number for this enrolment needs to be verified |
| 410 | Age restriction applies for this item - verify details |
| 411 | MBAC determination/precedent number not supplied or invalid |
| 412 | Benefit not payable - provider unable to claim this service |
| 413 | Benefit not payable - date of service prior to date of request |
| 414 | Provider practice location is closed at date of service |
| 415 | Referral details same as rendering provider - self-deemed? |
| 416 | Services form a composite item - composite item required |
| 417 | Referral needed - if no referral, no item to be transmitted |
| 418 | Item cannot be claimed more than once in one attendance |
| 419 | Benefit already paid on item - verify if multiple pregnancy |
| 420 | Operation/s schedule fee does not meet item description |
| 421 | Wrong assistant item used for the operation/s performed |
| 422 | Benefit paid has been reduced (benefit = charge) |
| 423 | Optical condition not specified - No benefit payable |
| 424 | More information required - which eye was treated |
| 425 | Benefit not payable - individual charges required |
| 426 | Indicate whether new treatment or continuing management |
| 427 | Compensation related services - please forward documents |
| 428 | Date of service over 2 years - late lodgement form required |
| 429 | Patient cannot be identified from the information supplied |
| 430 | Conflicting referral details - please clarify |
| 431 | Initial consultation previously paid - query subsequent con |
| 432 | Not Multi-op - more information required to pay benefit |
| 433 | Associated referral/request line not required |
| 434 | Expired or invalid card. Benefit not payable |
| 435 | Service for nursing home care recipient - benefit not paid |
| 436 | Cannot claim out of hospital service through Simplified bill |
| 450 | EFT details invalid - cheque issued for benefit |
| 461 | Adjustment to benefit previously paid |
| 475 | Patient/service details invalid or missing |
| 500 | Rejected in association with another item in this claim |
| 501 | Group attendance or item format invalid |
| 502 | Patient is not eligible to claim benefit for this item |
| 503 | Hospital service not payable under RHCA |
| 504 | Charge amount missing/invalid - no benefit payable |
| 505 | More information required. Evidence of condition |
| 507 | Site not accredited for this service |
| 511 | EMSN threshold reached - cap applied to benefit |
| 512 | Multiple Musculoskeletal MRI Service Rule applied |
| 513 | Multiple Musculoskeletal MRI and DI Services Rules applied |
| 514 | Required Equipment Type Code not on LSPN register |
| 515 | Equipment greater than 10 years old |
| 516 | Ben paid for base and derived radiotherapy items claimed |
| 517 | MPSN threshold reached - 80% out of pocket paid |
| 518 | Benefit paid at 100% schedule fee + EMSN |
| 519 | MPSN threshold reached - partial 80% out of pocket paid |
| 520 | Benefit paid at 100% schedule fee + part 80% out of pocket |
| 521 | Part 80% out of pocket + between 85% and 100% increase |
| 522 | Benefit paid - 80% out of pocket + between 85% and 100% increase |
| 524 | Safety net benefit adjusted |
| 525 | Only attracts benefit when claimed via bulk billing |
| 528 | Provider not in eligible area (incorrect RRMA,SSD or state) |
| 529 | Bulk bill additional item claimed incorrectly |
| 530 | Patient not on concession/under 16 years at date of service |
| 535 | Missing data |
| 536 | Location Specific Practice Number not supplied |
| 537 | Location Specific Practice Number invalid |
| 538 | Location Specific Practice Number not recognised |
| 539 | Location Specific Practice Number not valid at date of service |
| 540 | Enhanced primary care plan item not previously claimed |
| 541 | Allied Health referral form present |
| 542 | Allied Health referral form not present |
| 549 | Bulk bill incentive item already paid - adjustment required |
| 550 | Associated service not claimed - no benefit payable |
| 551 | Specimen collection point is incorrect or not supplied |
| 552 | Specimen collection point not valid at date of service |
| 553 | Approved collection centre number not supplied |
| 554 | Total benefit for Anaesthetic service |
| 555 | Benefit paid on Main RVG Anaesthetic item |
| 556 | RVG time item not claimed |
| 557 | Associated RVG anaesthetic service not claimed |
| 558 | RVG anaesthetic item not claimed |
| 559 | Patient outside age range - please verify age |
| 560 | RVG item restriction |
| 561 | Benefit paid on RVG item claimed |
| 562 | Benefit paid on associated RVG anaesthetic item |
| 563 | Associated RVG service already paid |
| 564 | Multiple Vascular Ultrasound services site rule applied |
| 565 | Multiple DI and Vascular Ultrasound service rules applied |
| 566 | Total benefit for Diagnostic Imaging Service |
| 567 | Benefit paid on main Diagnostic Imaging Item |
| 600 | Requesting/referring provider unable to be identified |
| 601 | In hospital services cannot be claimed as out of hospital |
| 602 | Out of hospital service cannot be claimed as in hospital |
| 603 | Newborn not yet enrolled with Medicare - no benefit payable |
| 604 | Service over 2 years old - late lodgement form required |
| 605 | Referral expired - no benefit payable |
| 606 | Referring provider number not open at date of referral |
| 607 | Referral date has been omitted |
| 608 | Referring and servicing provider same - no benefit payable |
| 609 | Service/Claim cancelled at providers request |
| 610 | Provider specialty not consistent with item claimed |
| 611 | Referral/request details not supplied - no benefit payable |
| 612 | Date of referral after date of service - no benefit payable |
| 613 | Card number cannot be identified from information supplied |
| 614 | No benefit payable - please notate time of each visit |
| 615 | Multiple procedures - notate times and area of treatment |
| 616 | Item cannot be claimed as in hospital service |
| 617 | Item cannot be claimed as out of hospital service |
| 618 | No benefit if requested by this provider at date of request |
| 619 | Servicing provider number not open at date of service |
| 620 | Duplicate transmission - no further payment made |
| 621 | Item not claimable electronically |
| 622 | PET drop-down items not claimable via EDI |
| 623 | PET items only claimable via direct bill |
| 624 | PET items - payee provider required |
| 625 | Payee provider not eligible to claim PET items |
| 627 | PDT statement not provided by the operator |
| 629 | Initial PDT therapy item not present on patient history |
| 633 | Refer back to the specialist - referring provider is closed |
| 634 | Refer back to the specialist - servicing provider is closed |
| 635 | Late Lodgement not approved - Letter being sent separately |
| 636 | Benefit reduced-dental cap broken |
| 637 | No benefit payable-dental cap reached |
| 700 | Benefit cannot be determined for this service |
| 701 | Benefit cannot be determined due to complex assessing rules |
| 702 | Item restrictive with another item |
| 703 | Duplicate of item already quoted |
| 704 | Provider not permitted to claim this item |
| 705 | No associated pathology service |
| 706 | Provider not associated with a pathology laboratory |
| 707 | Pathology laboratory not registered at date of service |
| 708 | Item cannot be claimed from this pathology laboratory |
| 709 | Another assistant item should be claimed |
| 710 | Associated surgical items not present |
| 711 | Unable to determine associated surgery |
| 712 | Base item not present or in incorrect order |
| 713 | Radiotherapy fields greater than maximum allowable |
| 714 | Benefit not determined - number of time units not present |
| 715 | Number of time units exceeded maximum allowable |
| 716 | Service forms a composite item - composite item required |
| 717 | Benefit not payable on this service for a hospital patient |
| 718 | Provider location closed at date of service |
| 719 | Benefit cannot be calculated for hyperbaric oxygen therapy |
| 732 | Referral period not valid for referring provider |
| 812 | Details of Revised Medicare Assessment |
| 816 | Details of Revised Medicare Assessment |
| 888 | Details of Previous Medicare Assessment |
| 889 | Details of Previous Medicare Assessment |
Last updated: 18 March, 2010
