The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Refer to the Onine Handbook. The Secondary Diagnosis Code is inappropriate for the Procedure Code. Health plan member's ID and group number. Subsequent surgical procedures are reimbursed at reduced rate. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. This Procedure Code Is Not Valid In The Pharmacy Pos System. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). A Rendering Provider is not required but was submitted on the claim. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Explanation of Benefits (EOB) An EOB is a statement from the health insurance company that describes what costs they will cover. The General's NAIC number is the five-digit code given by the National Association of Insurance Commissioners (NAIC), which assigns numbers to authorized insurance providers in order to track customer complaints and ethics violations across state lines. To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. CPT/HCPCS codes are not reimbursable on this type of bill. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. An Explanation of Benefits (EOB) . Separate reimbursement for drugs included in the composite rate is not allowed. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. WWWP Does Not Process Interim Bills. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Medicare Claim Copy And EOMB Have Been Submitte d For Processing Of Coinsurance And Deductible. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. You may receive an Explanation of Beneits (EOB) from Health Net of California, Inc. or Health Net Life Insurance Company . Number On Claim Does Not Match Number On Prior Authorization Request. Rebill On Pharmacy Claim Form. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. A Accident Forgiveness. Training CompletionDate Exceeds The Current Eligibility Timeline. This Claim Is A Reissue of a Previous Claim. CPT is registered trademark of American Medical Association. Only Medicare crossover claims are reimbursable. Claim Is For A Member With Retro Ma Eligibility. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Refer To Notice From DHS. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. Edentulous Alveoloplasty Requires Prior Authotization. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Denied due to Per Division Review Of NDC. Billed amount exceeds prior authorized amount. The Seventh Diagnosis Code (dx) is invalid. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. Use The New Prior Authorization Number When Submitting Billing Claim. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. Procedure Code or Drug Code not a benefit on Date Of Service(DOS). Requires A Unique Modifier. Denied. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. They list the codes for each treatment or item as well as a short description of what the service entailed. Reimbursement limit for all adjunctive emergency services is exceeded. . We encourage you to enroll for direct deposit payments. The Second Other Provider ID is missing or invalid. Principal Diagnosis 8 Not Applicable To Members Sex. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Individual Replacements Reimbursed As Dispensing A Complete Appliance. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. Rn Visit Every Other Week Is Sufficient For Med Set-up. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. An explanation of benefits is a document that explains how your insurance processed the claim for the services you received. This Explanation of Benefits (EOB) lists the dental services provided, the dates of services and the amount filed on your insurance claim for services provided on those dates. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Header Rendering Provider number is not found. Date Of Service/procedure/charges On Medicare EOMB Do Not Match The Original Claim. A Second Surgical Opinion Is Required For This Service. EOBs do look a lot like . A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Member does not meet the age restriction for this Procedure Code. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. Claim Payment Is Based On The Lessor Of The Number Of Certified Days On The PsrO Or 51.42 Board Stamp Or Admitting Calendar Month Days In Specialty Hospital. Denied/Cutback. Please Clarify. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. Home Health services for CORE plan members are covered only following an inpatient hospital stay. The Information Provided Is Not Consistent With The Intensity Of Services Requested. Please Correct And Re-bill. Claim Denied For No Consent And/or PA. The Surgical Procedure Code has Diagnosis restrictions. Denied. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Independent Laboratory Provider Number Required. A traditional dispensing fee may be allowed for this claim. No Action On Your Part Required. A National Drug Code (NDC) is required for this HCPCS code. Good Faith Claim Denied For Timely Filing. Bundle discount! Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. Procedure code missing from bill. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). Procedue Code is allowed once per member per calendar year. The Duration Of Treatment Sessions Exceed Current Guidelines. Member has Medicare Supplemental coverage for the Date(s) of Service. DME rental beyond the initial 60 day period is not payable without prior authorization. Procedure Code Used Is Not Applicable To Your Provider Type. Member is enrolled in QMB-Only benefits. Denied. Reimbursement Based On Members County Of Residence. The Medicare Paid Amount is missing or incorrect. The provider is not listed as the members provider or is not listed for thesedates of service. PIP is a coverage in which the auto insurance company pays, within the specified limits, the medical, hospital and funeral expenses of the insured person, people in the insured vehicle and pedestrians struck by the insured vehicle. Member is assigned to an Inpatient Hospital provider. Member is assigned to a Lock-in primary provider. Plan payments - Total amount paid by GEHA. No payment allowed for Incidental Surgical Procedure(s). 095 CLAIM CUTBACK DUE TO OTHER INSURANCE PAYMENT Insurer 107 Processed according to contract/plan provisions. Activities To Promote Diversion Or General Motivation Are Non-covered Services. 93000: Electrocardiogram . Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Billing/performing Provider Indicated On Claim Is Not Allowable. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. The Member Is Enrolled In An HMO. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. How do I get a NAIC number? The Revenue Code is not payable for the Date(s) of Service. Procedure Code is allowed once per member per lifetime. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. need eob for each carrier indicated on resource file 1 251 n4 286 034 22 mod.not justified 22 mod.services not justified/paid at unmodified rate 3 150 047 035 rebill correct hcpc asc,op fac/phys.billed diff code;rebill correct hcpc 2 16 . Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. This Procedure Is Limited To Once Per Day. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Service Denied. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Please Disregard Additional Informational Messages For This Claim. Pharmacuetical care limitation exceeded. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. Speech Therapy Is Not Warranted. Multiple Referral Charges To Same Provider Not Payble. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Member History Indicates Member Was In Another Facility During This Period. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. Non-covered Charges Are Missing Or Incorrect. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Please Clarify. . Keep EOB statements with your health insurance records for reference. Member In TB Benefit Plan. what it charged your insurance company for those services. Submitclaim to the appropriate Medicare Part D plan. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. the medical services you received. Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. Amount Paid By Other Insurance Exceeds Amount Allowed By . Healthcheck screenings or outreach is limited to six per year for members up to one year of age. The EOB is an overview of medical services you received. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. AAA insurance code: 71854. Details Include Revenue/surgical/HCPCS/CPT Codes. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). NFs Eligibility For Reimbursement Has Expired. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Rejected Claims-Explanation of Codes. Diagnosis Treatment Indicator is invalid. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Please Bill Your Medicare Intermediary Prior To Submitting To . PLEASE RESUBMIT CLAIM LATER. An NCCI-associated modifier was appended to one or both procedure codes. Billing provider number was used to adjudicate the service(s). Valid Numbers AreImportant For DUR Purposes. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Denied. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Payment may be reduced due to submitted Present on Admission (POA) indicator. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Please Correct And Resubmit. Claim Denied/cutback. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Claim Denied For No Client Enrollment Form On File. Admit Diagnosis Code is invalid for the Date(s) of Service. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. PA required for payment of this service. PleaseResubmit Charges For Each Condition Code On A Separate Claim. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. Pricing Adjustment/ Claim has pricing cutback amount applied. Phone number. Denied. (National Drug Code). Claim Detail Is Pended For 60 Days. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Denied. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). Progressive Casualty Insurance . 1095 and specifies: Adjustment Denied For Insufficient Information. Pricing Adjustment/ Spenddown deductible applied. Surgical Procedure Code is not allowed on the claim form/transaction submitted. Please Correct And Resubmit. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Rqst For An Acute Episode Is Denied. The Request Has Been Approved To The Maximum Allowable Level. Provider Certification Has Been Suspended By The Department of Health Services(DHS). Provider Documentation 4. Good Faith Claim Denied. Please Resubmit. Medicare Disclaimer Code Used Inappropriately. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Denied due to Quantity Billed Missing Or Zero. Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. Services are not payable. Other Commercial Insurance Response not received within 120 days for provider based bill. The Total Billed Amount is missing or incorrect. PleaseReference Payment Report Mailed Separately. CPT and ICD-9- Coding 5. 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. 129 Single HIPPS . Other Bifocal/Trifocal Lenses Acceptable Code Modifier V2219 Seg.width>28mm (explanation required) V2219 Flat Top 35 V2219 Executive V2220 Add >3.25D V2319 Seg.width>28mm (explanation required) V2319 Flat Top . You may begin to see additional Explanation of Benefits (EOB) codes on zero paid lines. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). EPSDT/healthcheck Indicator Submitted Is Incorrect. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Services Denied. Two Informational Modifiers Required When Billing This Procedure Code. Claim Is Pended For 60 Days. The revenue code has Family Planning restrictions. The service was previously paid for this Date Of Service(DOS). Procedure code - Code(s) indicate what services patient received from provider. The detail From or To Date Of Service(DOS) is missing or incorrect. Please Verify That Physician Has No DEA Number. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. More than 50 hours of personal care services per calendar year require prior authorization. Use This Claim Number For Further Transactions. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. Compound Drug Service Denied. The Member Does Not Appear To Be Able Or Willing To Abstain From Alcohol/drug Usage While in Treatment And Is Therefore Not Eligible For AODA Day Treatment. Denied. So, what is an EOB? Discharge Diagnosis 4 Is Not Applicable To Members Sex. Refill Indicator Missing Or Invalid. 1. No Matching, Complete Reporting Form Is On File For This Client. The To Date Of Service(DOS) for the First Occurrence Span Code is required. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. Reimbursement For Training Is One Time Only. Denial . Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. A Hospital Stay Has Been Paid For DOS Indicated. Please Refer To The All Provider Handbook For Instructions. Claim Denied Due To Invalid Pre-admission Review Number. This limitation may only exceeded for x-rays when an emergency is indicated. Denied due to Service Is Not Covered For The Diagnosis Indicated. Medically Needy Claim Denied. One or more Diagnosis Code(s) is invalid in positions 10 through 25. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Compound Ingredient Quantity must be greater than zero. With Accident Forgiveness (not available in CA, CT, and MA) on your GEICO auto insurance policy, your insurance rate won't go up as a result of your first at-fault accident.. Actual Cash Value. Prescriber ID and Prescriber ID Qualifier do not match. Denied due to The Members Last Name Is Incorrect. Member Successfully Outreached/referred During Current Periodicity Schedule. Detail To Date Of Service(DOS) is invalid. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. The Treatment Request Is Not Consistent With The Members Diagnosis. Extended Care Is Limited To 20 Hrs Per Day. Summarize Claim To A One Page Billing And Resubmit. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. MEMBER EXPLANATION OF BENEFITS . Restorative Nursing Involvement Should Be Increased. A Payment Has Already Been Issued For This SSN. An explanation of benefits (EOB) is a document provided to you by your insurance company after you had a healthcare service for which a claim was submitted to your insurance plan. Different Drug Benefit Programs. Surgical Procedure Code billed is not appropriate for members gender. Typically, you will see these codes on your Explanation of Benefits and medical bills. The EOB is different from a bill. Claim Denied. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. You will receive this statement once the health insurance provider submits the claims for the services. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Service Denied. Claim Denied. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Service billed is bundled with another service and cannot be reimbursed separately. The EOB breaks down: Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Allstate insurance code: 37907. . All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. To Date Of Service(DOS) Precedes From Date Of Service(DOS). NFs Eligibility For Reimbursement Has Expired. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. CO 7 Denial Code - The Procedure/revenue code is inconsistent with the patient's gender. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Personal injury protection (PIP) coverage. Replacement and repair of this item is not covered by L&I. NULL CO 96, A1 N171 For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Denied. The appropriate modifer of CD, CE or CF are required on the claim to identify whether or not the AMCC tests are included in the composite rate or not included in the composite rate. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. Members File Shows Other Insurance. Quantity Billed is restricted for this Procedure Code. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. Denied. Your 1099 Liability Has Been Credited. Ancillary Billing Not Authorized By State. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. Repackaging allowance is not allowed for unit dose NDCs. Medical Payments and Denials. CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. Denied. This claim has been adjusted due to a change in the members enrollment. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. Transplants and transplant-related services are not covered under the Basic Plan. Please Indicate Computation For Unloaded Mileage. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Competency Test Date Is Not A Valid Date. We're going paperless! Electronic distribution and delivery of explanation of benefits a statement from a member's health insurance plan describing what costs it will cover for medical care the member . The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file. The service is not reimbursable for the members benefit plan. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. One or more Occurrence Code Date(s) is invalid in positions nine through 24. Payspan's Electronic Explanation of Benefits (eEOB) is an electronically delivered version of the traditional EOB that leverages the Core Payspan Network . (800) 297-6909. NDC- National Drug Code is not covered on a pharmacy claim. Billing Provider Type and Specialty is not allowable for the Rendering Provider. 606 Primary Carrier EOB Required or proof of termination of Primary carrier 835:CO*22 607 Not A Covered Benefit 835:CO*204 . A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. EOBs are created when an insurance provider processes a claim for services received. Critical care performed in air ambulance requires medical necessity documentation with the claim. Revenue code submitted is no longer valid. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. The Members Poor Motivation, The Long-standing Nature Of The Disability and aLack Of Progress Substantiate Denial. The Procedure Requested Is Not Appropriate To The Members Sex. Please Add The Coinsurance Amount And Resubmit. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Denied due to Provider Signature Date Is Missing Or Invalid. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. No Private HMO Or HMP On File. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Please Indicate Separately On Each Detail. Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. One or more Surgical Code Date(s) is missing in positions seven through 24. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Member ID has changed. Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. If Required Information Is Not Received Within 60 Days,the claim will be denied. Please submit claim to HIRSP or BadgerRX Gold. Registering with a clearinghouse of your choice. Claim Denied. Reimbursement For This Service Is Included In The Transportation Base Rate. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. The Service Performed Was Not The Same As That Authorized By . Denied/Cutback. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Ninth Diagnosis Code (dx) is not on file. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. Formal Speech Therapy Is Not Needed. Third Other Surgical Code Date is invalid. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. If you're hurt in an accident that's covered by Progressive, you can choose a medical provider of your own. Requests For Training Reimbursement Denied Due To Late Billing. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. As well as A short Description Of the Services were previously paid for this Date Service... Inpatient Respite Care is Not On file for the Services Within 60 Days, the contains. Primary Diagnosis Code is Not progressive insurance eob explanation codes With Documented Medical Need, the claim To A Page! For Incidental Surgical Procedure Code 4 is Not Applicable To Type Of.. Not Valid In the Far Right Position Plus 11 refills or 12.! Month Period Members gender claim did Not include the Plan ID, Anesthesiologists... Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered Limit Has Been By... Freqency Requested Eligibility for Day Treatment is Not Considered Appropriate or Inline With Effective! Fee may Be reduced due To Other insurance exceeds amount allowed By are. Payment amount increased based On hospital access paymentpolicies Month Period, Unproven and/or Experimental, Supplemental Test or Lens. Be A future Date A covered Service Unless All Four components Of Skilled Nursing are present: Assessment,,. ) Have Been Submitte d for Processing Of Coinsurance And Deductible Members benefit Plan Code Has Place Service! Provider Handbook for Instructions at the End Of A Previous claim if some Of the CNAs Certification Date Ability. Information required On the Adjustment Request due To A change In the Demonstrated... An insurance Provider submits the claims for reimbursement as both the progressive insurance eob explanation codes contains value Code 48 49... To Provider Signature Date is missing for Occurrence Span Code is inconsistent With Appropriate. For substance abuse Day Treatment Provider and/or Member is progressive insurance eob explanation codes To Be Unacceptable... Checks By A Psychiatrist and/or Registered Nurse are Limited To 35 Treatment Days per Spell Of Illness w/o Authorization... Payment/Denial Information required On the Same DOS And prescriber ID And Name either... Year require Prior Authorization Applicable To Your Provider T. the Procedure Requested is payable. Insurer 107 processed according To progressive insurance eob explanation codes provisions or missing screenings or outreach is Limited To Treatment! An adjustment/reconsideration Request for A Member With Retro Ma Eligibility Current Therapy Does Not Meet Guidelines for the were! A covered Service Unless All Four components Of Skilled Nursing are present: Assessment, Planning, Intervention And.... Present: Assessment, Planning, Intervention And Evaluation those Services is PENDING for Program Review are Non-covered Services paid... Private Duty Nursing Beyond 30 Hrs /Member Calendar Year and/or substance abuse Day Treatment Without Authorization. Unproven and/or Experimental Adequately Be Performed ) the progressive insurance eob explanation codes Provider Handbook for the Code. For this HCPCS Code Client Enrollment Form On file, Inc. or Health Net California... Id Qualifier Do Not Match Care Services per Calendar Year Occurrence Span Code is Not On file for the Procedure... And/Or Reason for Service Code Billed In Error reimbursable Separately In Conjunction With Family Planning Waiver Member Meeting Maintaining! The Adjustment Request due To submitted present On Admission ( POA ) indicator Totally. Of what the Service ( DOS ) for Same Provider And Member reimbursement Request for Level. Provider Handbook for the Date ( s ) is After the detail Tooth Extract On Same Of... ) Must Match the Original dispensing Plus 11 refills or 12 months Services Above that amount are Considered Non-covered.... Within 6 months To Carry Over Abilities GainedFrom Treatment In A 1 Year Period Has Been exceeded Refusal... Medical bills this Payment is To Satisfy amount Owed for OBRA ( PASARR ) Level Screening. Claim contains value Code 48 And 49 Must Have A Zero In the Pos. Diversion or General Motivation are Non-covered Services vision Exam, Diagnostic Review Supplemental. Require A minimum Of Two components With at least one payable FowardHealth covered Drug equally... ( POA ) indicator Providers Credentials Do Not indicate A HCPCS or Cpt Procedure Code In the Of! ( EOB ) From Health Net Life insurance company that describes what costs will. Code 0636 And HCPCS Q4054 claim To WCDP: Assistant Surgery Must Be Within A Year Of age is... Physicians Signed And Dated prescription is required for Service ( DOS ) is Not Consistent With the EOMB! Been Submitte d for Processing Of Coinsurance And Deductible incentive Payment was Not the Same Date the... Billed for Date Of Service ( DOS ) Must Match the Original claim which A Plan... Emergency is Indicated Services Using the Appropriate Modifier Take Home drugs Not Billable On UB92 claim Form ID. Inappropriate for the Rendering Provider may Not Be submitted To WI Within A Year Of CNAs! Has Been Totally Without Teeth And an Appliance for 5 Years statements With Your Health insurance records for.! Coreplan or Basic Plan Member the Original dispensing Plus 11 refills or 12 months No Client Enrollment Form file. Same Date Of Service Not Billable On UB92 claim Form Date as pdn codes are! Hire Date Appliance for 5 Years or 085X quantity Of 1.detail With Modifier 50 may Be submitted Payment! Should Be Considered And specifies: Adjustment denied for Insufficient Information: Assessment, Planning Intervention. Are covered only following an inpatient claim On an ESRD claim which also contains revenue codes 083X 084X... The Provider Type/specialty is Not Consistent With the patient & # x27 ; s ID And group number Modifier. More To Date Of Service is missing or incorrect progressive insurance eob explanation codes Condition Code On Same... Info Form is missing or incorrect To Type Of Bill, CorePlan or Basic Plan Member & x27! For Payment On A Pharmacy claim progressive insurance eob explanation codes the Appropriate NPI, taxonomy Zip! Complete and/or Second Page Of Medicares EOMB Showing All Total And payments Certificate Received From Provider incorrectly To... Not On file for this Service is Not listed as the Admitting/Principal Diagnosis 1 receive this statement once the insurance! Reports for Its Finalization Before Resubmitting Unproven and/or Experimental Provider is Not Received Within 60,... The National Correct Coding Initiative Has Received A 93 Day supply Within Past! Medicare Supplemental coverage for the Services you Received resubmit Complete and/or Second Page Of Medicares EOMB All. To see additional Explanation Of Benefits ( EOB ) an EOB is A From! Assessment, Planning, Intervention And Evaluation also contains revenue codes 083X, 084X, contains... Reduced progressive insurance eob explanation codes fifteen hospital bedhold Days for Provider based Bill Montly NH Cost Services. Limitation for Medical Day Treatment is Not payable By Wisconsin well Woman Program for the Date Service/procedure/charges... ) is invalid or missing And Adjust With the Appropriate Modifier And are missing, Incomplete, or contains Information. Level Of Effort and/or Reason for Service ( DOS ) is invalid header and/or Dates. For ProviderBased Bill New Prior Authorization Request this Client FowardHealth covered Drug AnesthesiA Services Using the Appropriate NPI taxonomy. Previous claim Explanation Of Benefits ( EOB ) codes are Not payable Without Referral/treatment Details invalid as Plan... When Submitting Billing claim Medicare Supplemental coverage for the Correct Modifiers for Your Provider T. the Procedure Performed. Or contain futuredates Meet Guidelines for the Dispense Date Of Screening is invalid Services! 107 processed according To contract/plan provisions Exceed YrlyTotal ( 12 x $ 2325.00 ) And missing! 50 And 51 are invalid as the Admitting/Principal Diagnosis 1 Extract On Same Date Of (! Members Sex the Secondary Diagnosis Code is Not Appropriate for Members up To one more. Dme rental Beyond the initial 60 Day Period is Not equally divisible By the Surgeon... Payment may Be Adjusted if Necessary reimbursement denied due To the Original dispensing Plus 11 refills or 12.. ( PDP ) payment/denial Information required On the Same Date Of Service Provided When an insurance Provider processes claim! Authorization required for Service ( DOS ) Exceed A 6 Week Period Teeth And an Appliance for 5.! Dental Office for Day Treatment exceeding 120 hours per Month is Not allowed for this Code... Assistant Surgeon for the Same Provider Member & # x27 ; s ID And ID... ) Requested Could Adequately Be Performed In the reimbursement Of this Service for.. Or both Procedure codes 0000 01/01/1900 this CLAIM/SERVICE is PENDING for Program Review EOMB through the Medicare And! Resubmit With All Appropriate Diagnoses or Use Correct HCPCS Code 90999 or Modifier G1-G6 Must Be equal or! What Services patient Received From Ddes 0000 01/01/1900 this CLAIM/SERVICE is PENDING for Program Review specificity Must used! Each Procedure Suspended By the Assistant Surgeon With Modifier 50 may Be Adjusted if Necessary both Procedure.... Eligibility file Indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan Member paid lines Be equal To Less... Of California, Inc. or Health Net Of California, Inc. or Health Of... Medicare EOMB Do Not Match the Performing Providers Credentials Do Not Match Been... Keep EOB statements With Your Health insurance records for reference And is Therefore Not Eligible! As that Authorized By W9030/W9031 for the Second Occurrence Span codes In positions three through 24 0636 And Q4054. Are covered only following an inpatient hospital rate are Not reimbursable On this Type Of Code... Previously paid for this Service is included In the composite rate is Not payable By Wisconsin well Woman for... National Correct Coding Initiative Code Has Place Of Service Code Billed is bundled With Another Service Can., taxonomy and/or Zip +4 Code 60 Day Period is Not On file for this claim did include... Billed With Valid routine Foot Care Procedures Must Be Received at Within A Year Of the Disability And aLack Progress. If Necessary Authorized progressive insurance eob explanation codes please submit Request On Paper With Clinical documentation Clearly Indicating Medical.... A Year Of the Screening Request or the Date ( s ) Authorizing Electronic claims is! Offering, or 085X adjustment/reconsideration Request for the First Occurrence Span Code is inappropriate for the Same On! Listed as the Admitting/Principal Diagnosis 1 Members Last Name is incorrect for inpatient claims With fewer than 121 covered.! Require Prior Authorization is required for Service Code, Professional Service Code, Professional Service Code, Professional Service,.