Medigami Benchmarks: what medical bills and denials actually look like

Public federal and state data, decoded. Every number is reproducible from the cited source files.

Denial codes

• CO-4: procedure code inconsistent with modifier / missing modifier
• CO-11: diagnosis inconsistent with procedure
• CO-15: authorization number missing or invalid
• CO-16: claim lacks information / submission error
• CO-18: duplicate claim or service
• CO-22: care may be covered by another payer per COB
• CO-29: time limit for filing has expired
• CO-45: charge exceeds fee schedule/allowed/contracted amount
• CO-50: non-covered because not deemed medically necessary
• CO-55: procedure/treatment deemed experimental/investigational
• CO-56: procedure/treatment not proven effective
• CO-58: treatment was in an inappropriate/incorrect place of service
• CO-59: processed based on multiple/concurrent procedure rules
• CO-96: non-covered charge(s)
• CO-97: benefit included/bundled in another service already adjudicated
• CO-109: claim not covered by this payer/contractor
• CO-119: benefit maximum for time period/occurrence reached
• CO-151: payer deems the information does not support this many services
• CO-167: diagnosis/diagnoses not covered
• CO-197: precertification/authorization/notification absent
• CO-198: precertification/authorization exceeded
• CO-204: service/equipment/drug not covered under the plan
• CO-B7: provider not certified/eligible to be paid for this procedure/service on this date
• CO-B15: requires a qualifying service/procedure not received/adjudicated
• PR-1: deductible amount (patient responsibility)
• PR-2: coinsurance amount (patient responsibility)
• PR-3: copayment amount (patient responsibility)
• PR-96: non-covered charge (patient responsibility)
• PR-204: not covered under plan (patient responsibility)
• OA-23: impact of prior payer(s) adjudication
• N130: consult plan benefit documents for coverage/limitations
• N386: decision based on a National/Local Coverage Determination

ER cost-sharing by metro

• N/R
• Dallas-Fort Worth-Arlington, TX
• Houston-The Woodlands-Sugar Land, TX
• Austin-Round Rock-Georgetown, TX
• San Antonio-New Braunfels, TX
• Phoenix-Mesa-Chandler, AZ
• Atlanta-Sandy Springs-Alpharetta, GA
• Longview, TX
• Corpus Christi, TX
• Tyler, TX
• Richmond, VA
• Oklahoma City, OK
• Memphis, TN-MS-AR
• Indianapolis-Carmel-Anderson, IN
• Beaumont-Port Arthur, TX
• Miami-Fort Lauderdale-Pompano Beach, FL
• Nashville-Davidson--Murfreesboro--Franklin, TN
• Los Angeles-Long Beach-Anaheim, CA
• New Orleans-Metairie, LA
• Texarkana, TX-AR
• Las Vegas-Henderson-Paradise, NV
• Albuquerque, NM
• Odessa, TX
• Alexandria, LA
• New York-Newark-Jersey City, NY-NJ-PA
• Sacramento-Roseville-Folsom, CA
• Chicago-Naperville-Elgin, IL-IN-WI
• College Station-Bryan, TX
• Little Rock-North Little Rock-Conway, AR
• Tucson, AZ
• El Paso, TX
• Carson City, NV
• Tulsa, OK
• Tampa-St. Petersburg-Clearwater, FL
• St. Louis, MO-IL
• Laredo, TX
• Fort Smith, AR-OK
• Birmingham-Hoover, AL
• Victoria, TX
• Charlotte-Concord-Gastonia, NC-SC
• Amarillo, TX
• Modesto, CA
• Kansas City, MO-KS
• Las Cruces, NM
• Midland, TX
• Virginia Beach-Norfolk-Newport News, VA-NC
• Coeur d'Alene, ID
• Orlando-Kissimmee-Sanford, FL
• Columbus, OH
• Jackson, MS
• Seattle-Tacoma-Bellevue, WA
• Washington-Arlington-Alexandria, DC-VA-MD-WV
• McAllen-Edinburg-Mission, TX
• Detroit-Warren-Dearborn, MI
• Baton Rouge, LA
• Asheville, NC
• Shreveport-Bossier City, LA
• Cincinnati, OH-KY-IN
• Yuma, AZ
• Louisville/Jefferson County, KY-IN
• Charleston-North Charleston, SC
• Jacksonville, FL
• Dayton-Kettering, OH
• Abilene, TX
• Sherman-Denison, TX
• Riverside-San Bernardino-Ontario, CA
• Johnson City, TN
• Fayetteville-Springdale-Rogers, AR
• Chattanooga, TN-GA
• Brownsville-Harlingen, TX
• Roanoke, VA
• Lafayette, LA
• Raleigh-Cary, NC
• Topeka, KS
• Jefferson City, MO
• Augusta-Richmond County, GA-SC
• Wichita Falls, TX
• Killeen-Temple, TX
• San Angelo, TX
• Denver-Aurora-Lakewood, CO
• Greenville-Anderson, SC
• Fort Wayne, IN
• Prescott Valley-Prescott, AZ
• Savannah, GA
• Florence-Muscle Shoals, AL
• Kennewick-Richland, WA
• San Francisco-Oakland-Berkeley, CA
• Lubbock, TX
• Cape Coral-Fort Myers, FL
• Poughkeepsie-Newburgh-Middletown, NY
• Toledo, OH
• San Diego-Chula Vista-Carlsbad, CA
• Nacogdoches, TX
• Philadelphia-Camden-Wilmington, PA-NJ-DE-MD
• Gulfport-Biloxi, MS
• Kingsport-Bristol, TN-VA
• Montgomery, AL
• Deltona-Daytona Beach-Ormond Beach, FL
• Knoxville, TN
• Palm Bay-Melbourne-Titusville, FL
• Myrtle Beach-Conway-North Myrtle Beach, SC-NC
• Morristown, TN
• Wichita, KS
• Wilmington, NC
• Clarksville, TN-KY
• Pensacola-Ferry Pass-Brent, FL
• Gadsden, AL
• Lawton, OK
• Frankfort, KY
• Columbia, MO
• Cleveland-Elyria, OH
• Lake Charles, LA
• Oxnard-Thousand Oaks-Ventura, CA
• Columbus, MS
• Bellefontaine, OH
• Boston-Cambridge-Newton, MA-NH
• Milwaukee-Waukesha, WI
• Hartford-East Hartford-Middletown, CT
• Michigan City-La Porte, IN
• Athens-Clarke County, GA