Approved
Code Status What it means & what to do HPC
0000 | ✅ Approved | Claim approved — no action needed. | APPROVED |
Member/Membership
Code Status What it means & what to do HPC
0007 | ⚠ Waiting period | The member is still within their waiting period. Advise them to check when their cover begins. | WITHIN WAITING PERIOD |
0009 | ❌ Pre-existing condition | Not payable due to a pre-existing condition under the member's policy. | PRE-EXISTING CONDITION |
0019 | ❌ Patient not covered | The patient isn't covered for this service under their current policy. | PATIENT NOT COVERED |
0020 | ❌ No dependent status | The dependent status isn't valid for this member. Verify membership details. | NO DEPENDENT STATUS |
0021 | ❌ Invalid patient no. | The patient number isn't valid. Check the details and resubmit. | INVALID PATIENT NO |
0022 | ❌ Not covered | The membership doesn't cover this service. | MEMBERSHIP NOT COVERED |
0023 | ❌ Membership ceased | The membership is suspended or no longer active. The member needs to contact their fund. | MEMBERSHP CEASED/ SUSP |
0024 | ❌ Unfinancial | The membership isn't up to date with payments. The member needs to settle their account. | MEMBERSHP UNFINANCIAL |
0025 | ❌ No ancillary cover | This membership doesn't include ancillary cover for this service. | NO ANCILLARY COVER |
0034 | ❌ Age restriction | The member's age doesn't meet the requirements for this service. | AGE RESTRICTION |
0035 | ❌ Age restriction | The member's age doesn't meet the requirements for this service. | AGE RESTRICTION |
0036 | ❌ Gender restriction | The member's policy restricts this service by gender. | GENDER RESTRICTION |
0037 | ❌ Gender restriction | The member's policy restricts this service by gender. | GENDER RESTRICTION |
Item/Service
Code Status What it means & what to do HPC
0002 | ⚠ Restricted | This item has restrictions under the member's policy. Check the policy details before resubmitting. | RESTRICTED ITEM |
0003 | ⚠ Restricted | This item has restrictions under the member's policy. Check the policy details before resubmitting. | RESTRICTED ITEM |
0008 | ⚠ Prereq required | Another service must be claimed first. Check which prerequisite service is needed before resubmitting. | PREREQ SRVCE REQUIRED |
0010 | ❌ Invalid item no. | The item number isn't valid. Double-check the code and resubmit. | ITEM NO. IS NOT VALID |
0011 | ❌ Item ceased | This item number is no longer in use. Use the updated item code instead. | ITEM NO. CEASED USE |
0012 | ❌ Not for provider | This item isn't approved for your provider type. | ITEM NOT FOR PROVIDER |
0013 | ❌ Not approved | This item number isn't approved for this provider. Verify your provider details. | ITEM NO. NOT APPROVED |
0014 | ❌ Max uses reached | The maximum number of uses for this item has been reached. | ITEM MAX USE EXCEEDED |
0018 | ⚠ Body part needed | A body part is required for this service. Include it and resubmit. | BODY PART IS REQUIRED |
0040 | — Converted item | The item has been converted to a different code. Check the updated code on the response. | CONVERTED ITEM |
0051 | ❌ Not allowed | This item isn't available for your provider type. | NOT ALLOWED FOR PROV |
0052 | ⚠ Tooth no. needed | A tooth number is required. Include it and resubmit. | TOOTH NO REQUIRED |
0055 | ⚠ ICD-10 required | An ICD-10 code is required. Add it and resubmit. | ICD 10 CODE REQUIRED |
0058 | ❌ Non-telehealth item | This item can't be used for telehealth claims. Use the correct telehealth item code. | NON-TELEHEALTH ITEM USED |
Benefit & Limits
Code Status What it means & what to do HPC
0001 | ❌ Not payable | No benefit is payable for this item under the member's policy. | BENEFIT NOT PAYABLE |
0005 | ❌ Limit reached | The benefit limit for this service has been reached for this period. | BENEFIT LIMIT REACHED |
0006 | ❌ Limit reached | The benefit limit for this service has been reached for this period. | BENEFIT LIMIT REACHED |
0026 | ❌ Item not covered | The fund doesn't cover this item. | ITEM NOT COVERED |
Date & Timing
Code Status What it means & what to do HPC
0016 | ⚠ Invalid date | The service date appears invalid. Check the date and resubmit. | SERVICE DATE NOT VALID |
0017 | ⚠ Date too old | The service date is too far in the past. Contact support if you believe this is incorrect. | SERVICE DATE TOO OLD |
0053 | ❌ Date before injury | The service date is before the recorded injury date. Check the dates and resubmit. | DOS PRIOR TO INJURY DATE |
Billing & Charges
Code Status What it means & what to do HPC
0004 | — Already paid | This item has already been paid. Check your records before resubmitting. | PREVIOUSLY PAID |
0015 | ⚠ Fee missing | A service fee is required. Enter the fee and resubmit. | SERVICE FEE MISSING |
0027 | ⚠ Possible duplicate | This item appears to have already been submitted. Check your records before resubmitting. | POSSIBLE DUPLICATE |
0028 | ⚠ Excess applied | An excess applies — the benefit has been reduced accordingly. | EXCESS APPLIED |
0029 | ⚠ Excess applied | An excess applies — the benefit has been reduced accordingly. | EXCESS APPLIED |
0032 | ❌ Exceeds quotation | The item amount exceeds the approved quotation. Revise the amount or submit a new quotation. | EXCEEDS QUOTATION |
0033 | ❌ Exceeds quotation | The item amount exceeds the approved quotation. Revise the amount or submit a new quotation. | EXCEEDS QUOTATION |
0038 | ❌ Invalid charge | The charge entered isn't valid. Check the amount and resubmit. | INVALID CHARGE |
0039 | ⚠ Notional charge | The benefit has been calculated on a notional charge, not the amount entered. | NOTIONAL CHARGE |
0056 | ❌ Exceeds maximum | The charge exceeds the fund's maximum payable amount. Adjust the charge and resubmit. | CHARGE EXCEEDS MAXIMUM |
0057 | — Amount adjusted | The item amount has been adjusted by the fund — check the response for the updated figure. | ITEM AMOUNT ADJUSTED |
Admin & System
Code Status What it means & what to do HPC
0030 | ⚠ Quotation required | A quotation is required before this item can be paid. Submit a quote first. | QUOTATION REQUIRED |
0031 | ⚠ Quotation required | A quotation is required before this item can be paid. Submit a quote first. | QUOTATION REQUIRED |
0041 | — Refer to fund | The fund needs to review this item manually. No further action needed — wait for their response. | REFER TO FUND |
0042 | — System issue | A system issue occurred. Wait a moment and try again. Contact support if the issue persists. | SYSTEM PROBLEM |
0044 | ⚠ Medical cert needed | A medical certificate is required. Obtain and attach it before resubmitting. | MEDICAL CERT REQUIRED |
0050 | ❌ Unknown provider | The fund doesn't recognise this provider. Verify your provider registration details. | PROVIDER NOT KNOWN |
0054 | — Submitted | The item has been sent for manual processing — no further action needed right now. | SUBMITTED FOR PROCESSING |
