M204 | Coverage issue

Industry

Healthcare

Canonical

/healthcare/error-codes/m204/

Last Updated

Feb 25, 2026

Summary

This code indicates that a coverage-related issue affected claim adjudication.

Advertisement after-summary

Ad Space

What This Code Means

M204 is used when CMS identifies a problem related to coverage eligibility or benefit application. It does not specify the exact nature of the coverage issue. The code supports other adjustment or denial indicators. Coverage determinations depend on program rules and enrollment status.

Where Users Usually See This Code

Medicare remittance advice
EOB explanations
Coverage review notices

Why This Code Appears

Eligibility issues detected
Coverage rules not satisfied
Program limitations applied

What Typically Happens Next

Claim is denied or adjusted
Processing completes or pauses
Responsibility assigned per policy

What This Code Is Not

It is not a billing format error
It is not a documentation request
It is not a duplicate claim

Troubleshooting Checklist

□ Review eligibility status
□ Confirm coverage details
□ Monitor policy updates

Notes And Edge Cases

Coverage issues may arise from enrollment timing or program changes. Multiple coverage layers can complicate outcomes.

Related Codes

8 links

Advertisement near-bottom

Ad Space