Common 278 Rejection Reasons (AAA03)

AAA03 — Reject Reason Code (X12 element 901)

AAA (Request Validation), 278 response — returned at the loop level where the problem was found · 278 Health Care Services Review — Response (005010X217)

Draft — pending verification

This reference entry has not yet been verified against its authoritative source (X12 005010X217 TR3 / element 901 code list — verify against licensed copy). Do not rely on it for production configuration until this notice is removed.

Code	Name	Summary
15	Required application data missing	The request arrived structurally valid but is missing data the UM application needs to process it — the catch-all for incomplete requests that pass EDI validation yet cannot be adjudicated.
33	Input Errors	General input-error rejection: something in the submitted data is wrong in a way not covered by a more specific reason code.
35	Out of Network	The provider identified in the request is not in the network applicable to this member's benefit, and the payer's rules do not allow the review to proceed on that basis (or route it to an out-of-network review path)..
41	Authorization/Access Restrictions	The submitter is not authorized to make this request or access this information — a trading-partner permission problem rather than a clinical decision.
42	Unable to Respond at Current Time	The payer's system cannot process the request right now — downtime, backend unavailability, or timeout.
43	Invalid/Missing Provider Identification	The provider identifier in the request (typically the NPI) is missing, malformed, or does not resolve on the payer side.
44	Invalid/Missing Provider Name	The provider name is missing or fails validation against the payer's records — often a name/NPI mismatch where the identifier resolves but the name on file differs.
45	Invalid/Missing Provider Specialty	The provider taxonomy/specialty information is missing or invalid for the request — relevant where the payer's routing or review rules depend on specialty (e.g., specialist referral categories).
47	Invalid/Missing Provider State	The provider address state is missing or invalid.
49	Provider is Not Primary Care Physician	The requesting provider is not the member's primary care physician in a plan design that requires the PCP to originate this type of request (gatekeeper referral models).
50	Provider Ineligible for Inquiries	The provider is on file but not eligible to submit this kind of request to this payer — a permissions/enrollment state distinct from not being found at all.
51	Provider Not on File	The payer cannot find the provider in its files at all.
52	Service Dates Not Within Provider Plan Enrollment	The requested service dates fall outside the period the provider is enrolled/participating with the plan — a date-alignment failure between the request and the provider's contract span.
56	Inappropriate Date	A date in the request is inappropriate for its context — logically invalid rather than malformed, such as an admission date after the discharge date or an event date in an impossible relationship to others..
57	Invalid/Missing Date(s) of Service	The service date or date range is missing or invalid.
60	Date of Birth Follows Date(s) of Service	The member's date of birth is after the service dates in the request — a logical impossibility that almost always means a keying error in either the DOB or the service dates (newborn requests are the classic legitimate near-miss to check)..
64	Invalid/Missing Patient ID	The patient identifier is missing or fails validation.
65	Invalid/Missing Patient Name	The patient name is missing or does not match the payer's records closely enough — name-matching tolerance varies by payer, which makes this rejection frustratingly inconsistent across trading partners.
67	Patient Not Found	The payer cannot locate the patient at all with the submitted identification — the terminal member-matching failure after identifier and name edits pass individually.
72	Invalid/Missing Subscriber/Insured ID	The subscriber identifier is missing or invalid — the subscriber-level counterpart to code 64, and one of the highest-volume rejections in any real-time transaction because member ID entry is where human error concentrates..
73	Invalid/Missing Subscriber/Insured Name	The subscriber name is missing or fails the payer's matching rules — the same failure mode as code 65 but at the subscriber loop, meaning the policyholder's identification is what failed rather than a dependent's.
75	Subscriber/Insured Not Found	The payer cannot locate the subscriber with the submitted identification — often coverage termination, a plan migration, or simply the wrong payer.
77	Subscriber Found, Patient Not Found	The subscriber matched but the dependent patient did not — the payer knows the policyholder yet cannot find this dependent under the coverage, commonly a newborn not yet enrolled or a dependent listed differently..
78	Subscriber/Insured Not in Group/Plan Identified	The subscriber exists but not under the group or plan identified in the request — a stale or wrong group number, or a member who moved between the payer's plans.
79	Invalid Participant Identification	Identification of a participant in the transaction (requester, UMO, or another party in the exchange) is invalid — a routing/trading-partner identification failure rather than a member or provider data problem..
80	No Response Received - Transaction Terminated	A downstream system did not respond in time and the transaction was terminated — the payer-side timeout surfaced back to the submitter.
95	Patient Not Eligible	The patient is identified but not eligible for benefits relevant to the request — coverage found, eligibility failed.
98	Experimental Service or Procedure	The requested service is considered experimental or investigational under the plan's medical policy — a validation-level signal that the service falls in a category the plan does not certify through the standard path..
AA	Authorization Number Not Found	The certification/authorization number referenced in the request does not match any on file — fatal for renewals, extensions, revisions, cancellations, and appeals, which all depend on that linkage.
T4	Payer Name or Identifier Missing	The payer/UMO name or identifier is missing from the request — the transaction cannot even establish who is being asked to review it.