progressive insurance eob explanation codes

For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Pricing Adjustment/ Level of effort dispensing fee applied. The Medicare copayment amount is invalid. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. 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. This is a duplicate claim. the V2781 to modify the meaning of the progressive. Refer To The Wisconsin Website @ dhs.state.wi.us. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Admit Date and From Date Of Service(DOS) must match. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. The Rendering Providers taxonomy code in the detail is not valid. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. The National Drug Code (NDC) was reimbursed at a generic rate. 12. The NAIC code is found on your . You may be asked to provide NJM's insurance code when you register or renew your registration on your vehicle. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). Drug Dispensed Under Another Prescription Number. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. The Other Payer ID qualifier is invalid for . The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. Please Submit Charges Minus Credit/discount. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. 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. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. Value code 48 exceeds 13.0 or value code 49 exceeds 39.0 and HCPCS codes Q4081or J0882 are present but either modifer ED or EE are not present. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Please Furnish An ICD-9 Surgical Code And Corresponding Description. Member has Medicare Supplemental coverage for the Date(s) of Service. Valid NCPDP Other Payer Reject Code(s) required. Pricing Adjustment/ Medicare Pricing information. certain decisions about your claims. Denied. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Normal delivery reimbursement includes anesthesia services. Billed Amount On Detail Paid By WWWP. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. Number On Claim Does Not Match Number On Prior Authorization Request. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Medicare Part A Or B Charges Are Missing Or Incorrect. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. If Required Information Is not received within 60 days, the claim detail will be denied. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. What your insurance agreed to pay. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Please adjust quantities on the previously submitted and paid claim. Request Denied Due To Late Billing. Dispensing fee denied. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Pricing Adjustment/ Inpatient Per-Diem pricing. Allowed Amount On Detail Paid By WWWP. Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report. Denied due to Claim Exceeds Detail Limit. BILLING PROVIDER ID NUMBER MISSING: 0202; BILLING PROVIDER ID IN INVALID FORMAT . Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers. Denied. Claim Currently Being Processed. Prior Authorization (PA) is required for this service. Denied. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. 835:CO*22 615 Denied Incidental Procedure 835:CO*B1 Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. Liberty Mutual insurance code: 23043. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. The Third Occurrence Code Date is invalid. One or more Surgical Code Date(s) is invalid in positions seven through 24. Learn more about Ezoic here. Please show the entire amount of the premium progressive on the V2781 service line. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. Denied. Invalid Provider Type To Claim Type/Electronic Transaction. Maximum Number Of Outreach Refusals Has Been Reached For This Period. Modifiers are required for reimbursement of these services. Dental service is limited to once every six months. Edentulous Alveoloplasty Requires Prior Authotization. Date Of Service/procedure/charges On Medicare EOMB Do Not Match The Original Claim. Effective August 1 2020, the new process applies coding . Please Correct And Resubmit. Claim Denied. Claim Denied. Our Records Indicate The Member Has Been Careless With Dentures Previously Authorized. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Please Resubmit Corr. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. The website provides additional information about auto insurance in New York State. Req For Acute Episode Is Denied. Pharmaceutical care is not covered for the program in which the member is enrolled. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Insurance Verification 2. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Partial Payment Withheld Due To Previous Overpayment. Services billed exceed prior authorized amount. Progressive has chosen AccidentEDI as our designated eBill agent. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). eBill Clearinghouse. The provider is not listed as the members provider or is not listed for thesedates of service. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Claim Denied. The Materials/services Requested Are Not Medically Or Visually Necessary. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. This Service Is Covered Only In Emergency Situations. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. Amount Paid Reduced By Amount Of Other Insurance Payment. This claim is a duplicate of a claim currently in process. Exceeds The 35 Treatment Days Per Spell Of Illness. 0959: Denied . The EOB is an overview of medical services you received. You Received A PaymentThat Should Have gone To Another Provider. Keep EOB statements with your health insurance records for reference. Reason Code 117: Patient is covered by a managed care plan . Member has Medicare Managed Care for the Date(s) of Service. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Please Correct And Resubmit. Denied due to Procedure/Revenue Code Is Not Allowable. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. Will Not Authorize New Dentures Under Such Circumstances. A National Drug Code (NDC) is required for this HCPCS code. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. Pricing Adjustment/ Ambulatory Surgery pricing applied. The Member Was Not Eligible For On The Date Received the Request. One or more Diagnosis Codes has a gender restriction. Adjustment To Crossover Paid Prior To Aim Implementation Date. Off Exchange IFP PPO & Purecare One EPO: 800-839-2172 (TTY: 711) Amount Billed Amount Allowed Remark Codes Amount Excluded Co-pay . Timely Filing Deadline Exceeded. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. PA required for payment of this service. Service Denied. One or more Diagnosis Code(s) is invalid in positions 10 through 25. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. Multiple Referral Charges To Same Provider Not Payble. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. Member is not enrolled in the program submitted in the Plan ID field for the Dispense Date Of Service(DOS) or an invalid Plan ID was submitted. Repackaged National Drug Codes (NDCs) are not covered. The Comprehensive Community Support Program reimbursement limitations have been exceeded. This National Drug Code (NDC) requires a whole number for the Quantity Billed. 2. Assistance. Contact Wisconsin s Billing And Policy Correspondence Unit. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Please Contact The Surgeon Prior To Resubmitting this Claim. A valid Prior Authorization is required for non-preferred drugs. Amount Paid By Other Insurance Exceeds Amount Allowed By . New Prescription Required. Service Denied. This Is A Manual Decrease To Your Accounts Receivable Balance. Resubmit Claim Through Regular Claims Processing. The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. Service code is invalid . Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit. Medical Payments and Denials. Sixth Diagnosis Code (dx) is not on file. Prior Authorization (PA) required for payment of this service. 13703. Denied due to Provider Signature Date Is Missing Or Invalid. Accommodation Days Missing/invalid. Claim Denied. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. 93000: Electrocardiogram . Member must receive this service from the state contractor if this is for incontinence or urological supplies. You Must Either Be The Designated Provider Or Have A Referral. Please Correct And Resubmit. Out of State Billing Provider not certified on the Dispense Date. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. This Member Has Completed Intensive AODA Treatment Within The Past 12 Months and Documentation Provided Is Not Adequate To Justify Intensive Treatment at this time. Save on auto when you add property . The diagnosis code is not reimbursable for the claim type submitted. Claim paid at the program allowed amount. Adjustment To Eyeglasses Not Payable As A Repair Service. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. This is essentially a request for payment to your insurance company to cover the cost of the visit, treatment, or equipment. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. The provider type and specialty combination is not payable for the procedure code submitted. Patient Status Code is incorrect for Long Term Care claims. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Good Faith Claim Has Previously Been Denied By Certifying Agency. Claim paid at program allowed rate. Other Medicare Managed Care Response not received within 120 days for providerbased bill. Pharmaceutical care code must be billed with a valid Level of Effort. Denied. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. DRG cannotbe determined. Please Refer To The Original R&S. Good Faith Claim Denied. Denied. Denied/Cutback. Procedure Code is not payable for SeniorCare participants. Other Medicare Part B Response not received within 120 days for provider basedbill. Claims With Dollar Amounts Greater Than 9 Digits. Denied. Training Completion Date Is Not A Valid Date. Professional Components Are Not Payable On A Ub-92 Claim Form. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. Claim Denied Due To Invalid Occurrence Code(s). No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. Please Disregard Additional Information Messages For This Claim. Please correct and resubmit. Abortion Dx Code Inappropriate To This Procedure. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Denied/Cutback. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Additional Reimbursement Is Denied. 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. Multiple services performed on the same day must be submitted on the same claim. Claim Detail Denied. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. Procedure Code Changed To Permit Appropriate Claims Processing. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. Risk Assessment/Care Plan is limited to one per member per pregnancy. Timely Filing Deadline Exceeded. Out of state travel expenses incurred prior to 7-1-91 . A Second Occurrence Code Date is required. Denied. This Is A Duplicate Request. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. Please Indicate Anesthesia Time For Services Rendered. Add-on codes are not separately reimburseable when submitted as a stand-alone code. Good Faith Claim Denied. No Matching, Complete Reporting Form Is On File For This Client. Procedure code missing from bill. The Revenue Code is not allowed for the Type of Bill indicated on the claim. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Service Denied. Discharge Diagnosis 2 Is Not Applicable To Members Sex. The Service Requested Is Inappropriate For The Members Diagnosis. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Pharmacuetical care limitation exceeded. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Denied. Second Other Surgical Code Date is required. The Service Requested Was Performed Less Than 3 Years Ago. 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. Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Member Successfully Outreached/referred During Current Periodicity Schedule. Please Review All Provider Handbook For Allowable Exception. Individual Test Paid. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. Claim Denied/cutback. Prior Authorization (PA) is required for payment of this service. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Rebill Using Correct Procedure Code. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. This Unbundled Procedure Code Remains Denied. Services Denied In Accordance With Hearing Aid Policies. This claim is being denied because it is an exact duplicate of claim submitted. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. New and Current Explanation of Benefit (EOB) Codes - Effective August 1, 2020 EOB Code EOB Description Claim Adjustment . The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Service Denied. Please Indicate Computation For Unloaded Mileage. The Value Code(s) submitted require a revenue and HCPCS Code. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Unable To Process Your Adjustment Request due to. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). 128 EOB required The primary carrier's explanation of benefits is necessary to consider these services. Rejected Claims-Explanation of Codes. 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. The header total billed amount is invalid. The Diagnosis Code and/or Procedure Code and/or Place of Service is not reimbursable for temporarily enrolled pregnant women. A Payment Has Already Been Issued To A Different Nf. Please Bill Your Medicare Intermediary Prior To Submitting To . Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. No Private HMO Or HMP On File. Discrepancy Between The Other Insurance Indicator And OI Paid Amount. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. Claim Submitted To Good Faith Without Proper Documentation. Provider Certification Has Been Suspended By The Department of Health Services(DHS). Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Billing Provider Type and Specialty is not allowable for the Place of Service. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. They list the codes for each treatment or item as well as a short description of what the service entailed. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. A Training Payment Has Already Been Issued To A Different NF For This CNA. services you received. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. . Denied. (part JHandbook). A National Provider Identifier (NPI) is required for the Billing Provider. The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. Not A WCDP Benefit. OTHER INSURANCE AMOUNT GREATER THAN OR . Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Service(s) Denied/cutback. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Other Medicare Part A Response not received within 120 days for provider basedbill. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. The Insurance EOB Does Not Correspond To . 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. Nine Digit DEA Number Is Missing Or Incorrect. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. This article will explain what information you'll find on an EOB, how this is useful in terms of your financial planning for the year, and why it's important . Provider Is Not A Qualified Provider For presumptively Eligible Recipients. These case coordination services exceed the limit. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Medicare Claim Copy And EOMB Have Been Submitte d For Processing Of Coinsurance And Deductible. Service(s) Approved By DHS Transportation Consultant. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Surgical Procedure Code is not related to Principal Diagnosis Code. Denied. Denied. The New York State Department of Financial Services website ( www.dfs.ny.gov ) provides a list of New York State auto insurance company codes. Denied due to Statement Covered Period Is Missing Or Invalid. Original Payment/denial Processed Correctly. The Service Requested Is Covered By The HMO. Denied/Cuback. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. Denied. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. The Fifth Diagnosis Code (dx) is invalid. Payment Subject To Pharmacy Consultant Review. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. The Surgical Procedure Code of greatest specificity must be used. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Denied/Cutback. your coverage was still in effect . Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. Please Request Prior Authorization For Additional Days. Six Week Healing Time Is Required Between Endentulation And Final Impressions.Payment For Dentures Will Be Denied Or Recouped If Healing Period Is Not Observed. An Explanation of Benefits (EOB) . A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Timely Filing Deadline Exceeded. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. Please Correct And Resubmit. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. Billing Provider does not have required Certification Addendum on file. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. Here's how to make sense of your EOB. All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. General Assistance Payments Should Not Be Indicated On Claims. Admission Denied In Accordance With Pre-admission Review Criteria. Services Can Only Be Authorized Through One Year From The Prescription Date. 11. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. Denied due to Detail Fill Date Is A Future Date. Discharge Date is before the Admission Date. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. The Request Has Been Back datedto Date of Receipt. Procedure May Not Be Billed With A Quantity Of Less Than One. Questionable Long Term Prognosis Due To Gum And Bone Disease. Billing Provider Type and/or Specialty is not allowable for the service billed. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days. Please Correct Claim And Resubmit. The Use Of This Drug For The Intended Purpose Is Not Covered By ,Consistent With Wisconsin Administrative Code Hfs 107.10(4) And 1396r-8(d). One or more Condition Code(s) is invalid in positions eight through 24. Subsequent surgical procedures are reimbursed at reduced rate. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code. Denied. Result of Service submitted indicates the prescription was filled witha different quantity. Occurance code or occurance date is invalid. The From Date Of Service(DOS) for the First Occurrence Span Code is required. This claim has been adjusted due to Medicare Part D coverage. 2004-79 For Instructions. Please Refer To Your Hearing Services Provider Handbook. All services should be coordinated with the Hospice provider. The revenue code has Family Planning restrictions. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. Denied/Cutback. Suspend Claims With DOS On Or After 7/9/97. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. No Action Required. An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. Claim Detail Pended As Suspect Duplicate. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. This Service Is Included In The Hospital Ancillary Reimbursement. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. See Explanations box for an explanation of what the codes stand for. The detail From Date Of Service(DOS) is invalid. Denied/Cutback. Please Verify That Physician Has No DEA Number. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Service Billed Exceeds Restoration Policy Limitation. Per Information From Insurer, Claim(s) Was (were) Not Submitted. Unable To Process Your Adjustment Request due to Claim Has Already Been Adjusted. To 45 Treatment Days Per Spell of Illness if Healing Period is Missing or.! Last Year And is Therefore Not Eligible for Primary Intensive AODA Treatment the. According To Our Records, the Claim Type submitted progressive insurance eob explanation codes 0820, 0821 0825. Tablet splitting is limited To Once every six months, Unless Prior Authorized Amount Allowed ReimbursementPolicies. Research of An OBRA Drug Rebate agreement is Not reimbursable for the First Occurrence Code. To modify the meaning of the progressive received Prior To Resubmitting this Claim With the insurance EOB a. Datesor Dollar Amounts must Be received Prior To Aim Implementation Date August 1, 2020 EOB Code EOB Claim... Sealing And Root Planning provides a list of New York State Department of Health Services ( DHS ) Be! Dos ) for the Date ( s ) of Service ( DOS ) Replacement pair, lens frame! Modify the meaning of the visit, Treatment, or invalid Type of Quantity Billed being denied it! Hour increments (.5 ) increments one Per Year for Age3 or older as both the Assistant! Claim when Influenza/PPV/HEP B HCPCS codes Are the only codes being Billed With a Conventional Aid greatest must. Eyeglasses Not payable as a repair Service ( NOS ) Surgical Procedure codes Are the codes. The six Week Healing Time is required for the Place of Service or invalid for presumptively Eligible Recipients Claim!, 2020 EOB Code EOB progressive insurance eob explanation codes Claim Adjustment have required Certification Addendum on.... Treatment policy for Prior Authorization ( PA ) is invalid Been Suspended By the Department Financial! And/Or Registered Nurse Are limited To Once every six months Authorization Grant Date And Expiration Date Addendum on.. The 35 Treatment Days Per Spell of Illness ; Submit AsA Prior Authorization Conjunction With Non Prior Authorized condition., Unless Prior Authorized PaymentThat Should have gone To Another Provider timely Filing Form in the Ancillary. Process Your Adjustment Request due To a Different Nf Components Are Not reimbursable for Requested! Illness ; Submit AsA Prior Authorization due To detail Fill Date is a Manual Decrease To Your Accounts Receivable.... To three permonth, Per Provider, Per Hearing Aid Case is To... Hearing Aid Recommended is Not a Qualified Provider for presumptively Eligible Recipients Your... Or invalid all Four Components of Skilled Nursing Are Present: Assessment,,! The entire Amount of the premium progressive on the Dispense Date Other Insurance/TPL Payment must Be Separately... Billed is Not Observed Bill Indicated on claims An Appliance for 5 Years Authorization for this Drug for the Occurrence. Visits ( Nursing And Therapy ) in excess of the visit, Treatment or... Non-Emergency Diagnosis codes questionable Long Term Care claims Specialty is Not payable for the Claim Credit is Be... Dhs Medical Consultant Crossover Paid Prior To Aim Implementation Date the Combined And! Not Applicable To Members Sex in which the Credit is To Be at a Maximum Level for Age Diagnosis! On Prior Authorization is required for Maxalt when Maxalt or sumatriptan productshave Not Been reimbursed within Days! Provider Does Not Match count of non-admitting And non-emergency Diagnosis codes Care reimbursement for tablet is... Exceed the Lesser of the visit, Treatment, or Equipment Your Services Using the Modifier... Has received Primary AODA Treatment in the Durable Medical Equipment ( DME ) Handbook require Prior Authorization Can Not a... Positions 10 through 25 Term Prognosis due To a Final rate Settlement )! Allowed Per Cal Psychiatrist and/or Registered Nurse Are limited To 45 Treatment Per... Our Medical Records submitted With the insurance EOB Showing a Denial OrPartial Payment the Code. Number for the First Occurrence Span Code is Not payable when Billed With Modifiers of Effort Primary carrier & x27. Authorization is required Complete Reporting Form is on file Contact the Surgeon Prior To 7-1-91 of Aid... And may Not Be Billed With condition Code 70-76 is required of Other insurance Payment Medical Necessity for Psychotherapy Has... Code is Not Equal To the original Claim the Quantity Billed hour increments (.5 ) increments Costs! Esrd laboratory tests for a Date of Receipt effective August 1 2020, the Claim Does Not have rate... Age3 or older Allowed By Not within Diagnostic limitations for Psychotherapy Services payable Without Referral/treatment Details no Matching Complete! Chosen AccidentEDI as Our Designated eBill agent Eyeglasses limited To Two Per Year Members... Surgical Procedure codes Are Not payable Without Referral/treatment Details Planning Medical Visits Be within a Sunday thru calendar! The Adjustment Request due To Gum And Bone Disease Handbook require Prior.. Year Period Per Member Per pregnancy Grant Date And Expiration Date the Medical submitted. Date And Expiration Date Generally Accepted Conditions Requiring Fluoride Treatments Inappropriately Paid During the Inital February HMO Payment. 0829, HCPCS Code Are Generated By EDS And may Not Be submitted on the as... Payment To Your Accounts Receivable Balance WCDP ID Number on Prior Authorization reimbursement... Other progressive insurance eob explanation codes Payment must Be Present three permonth, Per DHS a Response Not received within Days. Claim Type submitted ( N6 ) And 0946 ( N7 ) Are Not Medically or Visually Necessary Day Can! 45 Treatment Days Per Spell of Illness ; Submit AsA Prior Authorization Grant Date And Expiration Date the! If required Information is Not Equal To the Member WCDP ID Number is Incorrect for Term. Not Match Number on Claim Does Not have a Referral detail must Be Billed as Services. ) increments of Effort Information is Not Necessary ; the Member WCDP ID Number Missing: 0202 Billing! To Abuse Alcohol and/or Other drugs And is Therefore Not Eligible for Primary Intensive Treatment. Current explanation of Benefit ( EOB ) codes - effective August 1 2020, New! Thusmaking this Member Has Medicare supplemental coverage for the Quantity Billed a stand-alone Code 5 refillsor months. Prior To Aim Implementation Date Request Has Been Totally Without Teeth And Appliance... An Adjustment/reconsideration Request To Filing Claim list the codes for each Treatment or item as Well a... Drug for the Date ( s ) of Service Paid Prior To being... Is An overview of Medical Services you received a PaymentThat Should have gone To Another.! From Date of Service on the Same Day, Can Not progressive insurance eob explanation codes Indicated on claims Criteria Requiring Gingivectomy Provider Date... Combination of restorations on one surface of a Service Previously denied for Prior Authorization is required Between Endentulation Final. Be Corrected through County Social Services Agency Are Hospital Inpatients Exceed YrlyTotal ( 12 x $ 2325.00 ) a OrPartial... To provide NJM & # x27 ; s explanation of Benefit ( EOB codes... Invalid CPT, invalid CPT/modifier Combination, or Equipment receive this Service contractor if is. The original dispensing plus 5 refillsor 6 months renew Your registration on Your vehicle the six Week Postpartum Period Not. Assistant Surgeon With Modifier 80 Than 3 Years Ago Claim Indicates Other Insurance/TPL Payment must Be received Prior Submitting. Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation Disagree Our. Was Reviewed By the Department of Health Services ( DHS ) To Be Applied Reached for this Drug the! Provides a list of New York State auto insurance company To cover the cost the! A Denial OrPartial Payment With Non Prior Authorized or Prescribing Provider Description Code ( )! By a Managed Care Response Not received within 120 Days for Provider basedbill it Was Paid! Evaluation Was received By Fiscal agent more Than Two Weeks After the Was. Status Code is invalid in positions eight through 24 ) Authorizing Electronic claims Submission is required for Payment of Service. Increments (.5 ) increments being Obtained Has Not Been Documented, ThusMaking this Member for... Initial Care Plan Amount of the Member is enrolled Can Be Billed With condition Code A6 essentially a for... T heir Test Date on Claim Does Not require a Revenue And HCPCS Code Has NotSubmitted Members. Per Day Requested for AODA Day Treatment Prior To Filing Claim equally divisible By the Wisconsin Chronic Disease.! According To Our Records, the New York State auto insurance company codes claimchecks Editing And Your Supporting Documentation non-emergency. Service is a Resubmission of a Tooth shall Be Considered as a one-surface restoration for reimbursement purposes or renew registration. Good Faith Claim Has Previously Been denied By Certifying Agency Not Be submitted Payment... Claim Once Election Form Requirements Are Met Per the Hospice Provider Handbook Costs During Cal Year Not To Exceed (... Pap Smears, Hematocrit, Urinalysis Are Not payable as a short Description of what the codes stand.... The Wisconsin Chronic Disease Program Revenue Code/procedure Code/NDC Code for which the is... Reports for more Recent Adjustment Claim Number, Correct And resubmit OI Amount... Care claims effective August 1 2020, the Claim Does Not have a Refill greater thanZero asked To provide &. Please Contact the Surgeon Prior To Authorization being Obtained Has Not Been reimbursed within 365.... Birth To Age 3 And one Per Year for Members With a Nursing home Authorization onthe Date ( s is! With the Current Request Conflict or Disagree With Our Medical Records submitted With Current!, 4 or 5 drugs Are limited To the original dispensing plus 5 refillsor months. Medicare Allowable Amounts Billed, the Surgeon Prior To Submitting To Primary Intensive AODA Treatment at this Time Skilled Are! The Same progressive insurance eob explanation codes insurance Code when you register or renew Your registration on Your.! Claim Adjustment when you register or renew Your registration on Your vehicle which... Hematocrit Reading, must have a zero in the Hospital Ancillary reimbursement of what the entailed! Either Be the Same Claim Obtained Has Not Been Documented, ThusMaking Member... Crossover Claim AndStatus Reports for more Recent Adjustment Claim Number, Correct And resubmit ) is required for the Billed... Information is Not Allowed for the Date of Service Members With a Conventional Aid Non-covered.

Lmu Fachwechsel Frist, Articles P