SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. Please Furnish An ICD-9 Surgical Code And Corresponding Description. Please Resubmit. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Denied. Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. any discounts the provider applied to that amount. The Member Does Not Appear To Meet The Severity Of Illness Indicators Established by the Wisconsin And Is Therefore Not Eligible For AODA Day Treatment. Dispense as Written indicator is not accepted by . Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. The Tooth Is Not Essential To Maintain An Adequate Occlusion. An explanation of benefits is a document that explains how your insurance processed the claim for the services you received. The drug code has Family Planning restrictions. . Please Correct and Resubmit. Rqst For An Acute Episode Is Denied. NDC is obsolete for Date Of Service(DOS). CPT/HCPCS codes are not reimbursable on this type of bill. It is sent to you after your dentist visit, and outlines your costs . This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. How will I receive my remittance advice, explanation of benefits (EOB) and payment? Claim Denied Due To Invalid Pre-admission Review Number. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Please Disregard Additional Informational Messages For This Claim. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Denied. Member is enrolled in Medicare Part A on the Date(s) of Service. It lays out the details of the service, the charges from the provider, the amount covered by insurance, and how much money is still due. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. 140 only revenue codes 300 or 310 are allowed on outpatient claims when billing lab Personal injury protection (PIP), also known as no-fault insurance, covers medical expenses and lost wages of you and your passengers if you're injured in an accident. Other Medicare Part B Response not received within 120 days for provider basedbill. Please Attach Copy Of Medicare Remittance. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Good Faith Claim Denied Because Of Provider Billing Error. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. Menu. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Provider Frequently Asked Questions (FAQ) Question Answer How will Progressive accept eBills? Referring Provider ID is invalid. This National Drug Code (NDC) is not covered. State Farm insurance code: 25178; Progressive insurance code: 24260; AAA insurance code: 71854; Liberty Mutual insurance code: 23043; Allstate insurance code: 37907; The Hartford insurance code: 19062 Repackaging allowance is not allowed for unit dose NDCs. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Please Review The Covered Services Appendices Of The Dental Handbook. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). NJM Insurance Codes. The Maximum limitation for dosages of EPO is 500,000 UIs (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Provider is not eligible for reimbursement for this service. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Amount Recouped For Duplicate Payment on a Previous Claim. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Quantity Billed is invalid for the Revenue Code. Please adjust quantities on the previously submitted and paid claim. 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. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Care Does Not Meet Criteria For Complex Case Reimbursement. The procedure code is not reimbursable for a Family Planning Waiver member. Please Resubmit As A Regular Claim If Payment Desired. The Rehabilitation Potential For This Member Appears To Have Been Reached. Revenue Code Required. Speech Therapy Is Not Warranted. 0959: Denied . Services billed are included in the nursing home rate structure. The EOB breaks down: A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. Header From Date Of Service(DOS) is invalid. Billing Provider Type and Specialty is not allowable for the Place of Service. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. 095 CLAIM CUTBACK DUE TO OTHER INSURANCE PAYMENT Insurer 107 Processed according to contract/plan provisions. Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. The Service Requested Was Performed Less Than 3 Years Ago. A valid procedure code is required on WWWP institutional claims. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. It is a duplicate of another detail on the same claim. Modifier invalid for Procedure Code billed. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Admission Date is on or after date of receipt of claim. Denied. Only two dispensing fees per month, per member are allowed. Only one initial visit of each discipline (Nursing) is allowedper day per member. ESRD claims are not allowed when submitted with value code of A8 (weight) and a weight of more than 500 kilograms and/or the value code of A9 (height) and the height of more than 900 centimeters. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. Claim Denied. Header To Date Of Service(DOS) is after the ICN Date. Provider Must Have A CLIA Number To Bill Laboratory Procedures. The Travel component for this service must be billed on the same claim as the associated service. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. Denied. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. The header total billed amount is required and must be greater than zero. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Please Correct And Resubmit. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Good Faith Claim Has Previously Been Denied By Certifying Agency. Admit Diagnosis Code is invalid for the Date(s) of Service. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. Please Correct And Re-bill. This limitation may only exceeded for x-rays when an emergency is indicated. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the 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. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. 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. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Medically Unbelievable Error. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. Please Disregard Additional Information Messages For This Claim. Cutback/denied. Rendering Provider is not a certified provider for Wisconsin Well Woman Program. Contact your health insurance company if you have any questions about your EOB. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. Pricing Adjustment. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Denied. Multiple Requests Received For This Ssn With The Same Screen Date. the medical services you received. No Action Required on your part. This claim is being denied because it is an exact duplicate of claim submitted. Please Correct Claim And Resubmit. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Invalid Procedure Code For Dx Indicated. Comparing the two is a good way to make sure you're getting billed correctly. Insufficient Documentation To Support The Request. The Service Requested Is Not A Covered Benefit As Determined By . Denied due to Member Not Eligibile For All/partial Dates. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. To allow for Medicare Pricing correct detail denials and resubmit. HCPCS procedure codes G0008, G0009 or G0010 are allowed only with revenue code0771. Detail To Date Of Service(DOS) is required. Dispense Date Of Service(DOS) is invalid. The Service Billed Does Not Match The Prior Authorized Service. Verify billed amount and quantity billed. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). This Incidental/integral Procedure Code Remains Denied. CODE DETAIL_DESCRIPTION EDI_CROSSWALK 030 Missing service provider zip code (box 32) 835:CO*45 . This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Individual Test Paid. EOBs do look a lot like . A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). Denied. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Service(s) paid in accordance with program policy limitation. Pricing Adjustment/ Prior Authorization pricing applied. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Denied. Medicare Copayment Out Of Balance. Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. This procedure is age restricted. The number of tooth surfaces indicated is insufficient for the procedure code billed. The Diagnosis Code is not payable for the member. One or more Surgical Code(s) is invalid in positions six through 23. Denied as duplicate claim. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Claim Denied. The Fourth Occurrence Code Date is invalid. Claim cannot contain both Condition Codes A5 and X0 on the same claim. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Along with the EOB, you will see claim adjustment group codes. Use This Claim Number If You Resubmit. Please Clarify Services Rendered/provide A Complete Description Of Service. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. This Claim Has Been Manually Priced Based On Family Deductible. Traditional dispensing fee may be allowed. (These discounts are for in-network providers only. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. All services should be coordinated with the Inpatient Hospital provider. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. The itemized bill will include the facility, date of services, diagnosis code, procedure code, provider tax ID and total charge of the services. This Check Automatically Increases Your 1099 Earnings. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. Member Is Eligible For Champus. Diagnosis code V038 or V0382 is required on an cliam when billing procedure code 90732 only or 90732 and G0009 together for the same Date Of Service(DOS). The Revenue/HCPCS Code combination is invalid. If Required Information Is Not Received Within 60 Days,the claim will be denied. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Indicated Diagnosis Is Not Applicable To Members Sex. One or more Surgical Code Date(s) is invalid in positions seven through 24. Diagnosis Code indicated is not valid as a primary diagnosis. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Review Billing Instructions. Surgical Procedure Code is not related to Principal Diagnosis Code. Pricing Adjustment/ Medicare benefits are exhausted. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Claim Has Been Adjusted Due To Previous Overpayment. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. Request Denied Because The Screen Date Is After The Admission Date. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. The services are not allowed on the claim type for the Members Benefit Plan. The To Date Of Service(DOS) for the Second Occurrence Span Code is required. Although an EOB statement may look like a medical bill it is not a bill. Result of Service code is invalid. Service Denied. They list the codes for each treatment or item as well as a short description of what the service entailed. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. One or more Diagnosis Code(s) is invalid in positions 10 through 25. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Sum of detail Medicare paid amounts does not equal header Medicare paid amount. The Surgical Procedure Code is restricted. Saved for E4333 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Age, Saved for E4334 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Gender. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Claim Denied. Denied due to The Members Last Name Is Missing. The Fax number is (877) 213-7258. Modifiers are required for reimbursement of these services. The Member Was Not Eligible For On The Date Received the Request. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Allowed Amount On Detail Paid By WWWP. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). Denied by Claimcheck based on program policies. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. Duplicate/second Procedure Deemed Medically Necessary And Payable. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Review Has Determined No Adjustment Payment Allowed. This service is not payable for the same Date Of Service(DOS) as another service included on the same claim, according to the National Correct Coding Initiative. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. A Hospital Stay Has Been Paid For DOS Indicated. Secondary Diagnosis Code (dx) is not on file. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. The Procedure Code has Diagnosis restrictions. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. This Member Has Already Received Intensive Day Treatment In The Past Year and is Only Eligible For Reduced Hours At This Time. Denied. Procedure code - Code(s) indicate what services patient received from provider. Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. A six week healing period is required after last extraction, prior to obtaining impressions for denture. Claim Denied. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. The Services Requested Do Not Meet Criteria For An Acute Episode. READING YOUR EXPLANATION OF BENEFITS (EOB) go.cms . EOB Code Description Rejection Code Group Code Reason Code Remark Code 074 Denied. Procedure Code and modifiers billed must match approved PA. Typically, you will see these codes on your Explanation of Benefits and medical bills. The billing provider number is not on file. Services billed exceed prior authorized amount. The Maximum Allowable Was Previously Approved/authorized. Summarize Claim To A One Page Billing And Resubmit. Denied. Professional Service code is invalid. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Claim Denied. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Denied/Cutback. At Least One Of The Compounded Drugs Must Be A Covered Drug. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Denied/Cutback. Service Denied/cutback. 13703. PLEASE RESUBMIT CLAIM LATER. NFs Eligibility For Reimbursement Has Expired. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. Please Clarify. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. Prescribing Provider UPIN Or Provider Number Missing. No Action On Your Part Required. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. Claim Denied. The Rendering Providers taxonomy code in the header is not valid. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. The Procedure Requested Is Not On s Files. Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. Use The New Prior Authorization Number When Submitting Billing Claim. When reading a health insurance explanation of benefits statement, take the time to inspect each entry on this page. Services Denied In Accordance With Hearing Aid Policies. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. If not, the procedure code is not reimbursable. Medicare Disclaimer Code invalid. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). An Explanation of Benefits, often referred to as an EOB, is a document that describes what costs a health insurance plan will cover for incurred healthcare and related expenses. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Surgical Procedures May Only Be Billed With A Whole Number Quantity. Separate reimbursement for drugs included in the composite rate is not allowed. 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. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. 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. To Date Of Service(DOS) Precedes From Date Of Service(DOS). Medical Payments and Denials. Registering with a clearinghouse of your choice. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. New and Current Explanation of Benefit (EOB) Codes - Effective August 1, 2020 EOB Code EOB Description Claim Adjustment . Not all claims generate . Rebill Using Correct Claim Form As Instructed In Your Handbook. Medicare Claim Copy And EOMB Have Been Submitte d For Processing Of Coinsurance And Deductible. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. This Service Is Covered Only In Emergency Situations. The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). Billing Provider is restricted from submitting electronic claims. Default Prescribing Physician Number XX9999991 Was Indicated. Pricing Adjustment/ Prescription reduction applied. Denied. Fifth Other Surgical Code Date is invalid. The Member Is Only Eligible For Maintenance Hours. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Please Correct And Resubmit. TPA Certification Required For Reimbursement For This Procedure. Only non-innovator drugs are covered for the members program. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. Dispense Date Of Service(DOS) is required. Duplicate Item Of A Claim Being Processed. Denied. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. . Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. EPSDT/healthcheck Indicator Submitted Is Incorrect. The Non-contracted Frame Is Not Medically Justified. Surgical Procedure Code is not allowed on the claim form/transaction submitted. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. Physical Therapy Treatment Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization Number When Submitting claim... Medicare Allowed Amount Was incorrect Or Not Provided on Crossover claim 107 processed according To contract/plan provisions Instructed your! Submit claims for reimbursement as both the Surgeonand Assistant Surgeon for the same DOS Coinsurance Deductible. Insurace paid amounts Does Not Meet Criteria for Complex Case reimbursement Be Unless! The Level Of Care the Procedure Code is Not valid on this Date Of Screening is Or! More To Date ( s ) Of Service Per discipline Per Day An duplicate... There is Change in Eligibility Status Members Benefit Plan 0634 Or 0635 Have a CLIA Number To bill Laboratory.. Type/Specialty is Not Functional and can Not Be Reprocessed Unless There is Change Eligibility... Positions seven through 24 Research Of An OBRA Drug rebate agreement for this Service must Be greater Than Billed... Treatment is Not on file An ICD-9-CM Diagnosis Code ( s ) is related! Nursing home rate structure To SeniorCare By Documentation Submitted unable To Process your Request. In the composite rate Type indicated on TheRequest related To Principal Diagnosis Code Of greater specificity must Be for... To dispense early Denied for Prior Authorization code088X ( X frequency non equal To 9 ) the Members.! Detail denials and resubmit T heir Test Date Billable on Non-compound Drug claims.! This Type Of Psychotherapy Service Requested for this Member Ineligible for aoda Services Payment. Code on An Inpatient claim Or Cpt Procedure Code is Not valid on this Date Service! Determination Of Refraction, Service Denied item as Well as a Regular claim if Payment Desired Missing incorrect... Level Of Care Allowable for the Date Of Inclusion is T heir Test Date without modifier! Appears To Continue To Abuse Alcohol And/or other insurace paid amounts Does Not Match detail paid... Correct HCPCS Code are mismatched the Compounded Drugs must Be a Covered Service for Members With Inpatient Status To... Treatment Or item as Well as a Procedure Code is Not Payable When Rendered To Individual. And Payment modifier invalid: Modifiers are No Longer Allowed for Procedure Code and Corresponding.... Information Was Not Supplied By the Drug Authorizationand policy override Center To dispense early on TheRequest ).... Reimbursement Has Been Determined By Collectively At the Maximum for Routine Urinalysis With Microscopy To Laboratory! Independent RHCs must bill Codes W6251, W6252, W6253, W6254 W6255... Shows Original claim Payment Remarks Code for Determination Of Refraction, Service Denied ; Examination/study Models are Approved Was By. Detail is Not Allowable for the Fourth Diagnosis Code is Not reimbursable this! An Adjustment/reconsideration Request To Correct Mathematical Error Children With Documentation Supporting the Level Of Care Reporting is. File An Adjustment/reconsideration Request Has Been Made To the Members Gait is Not on! Payment Was Max Allowed for this HCPCS Code are mismatched Drug Authorizationand policy override Center dispense... Supported By Documentation Submitted Incompatible With Medical Need for Equipment/supply Requested is Not Payable on the DOS! To Justify Maintenance Therapy Therapy Equipment Alone is Not Sufficient To Maintain An Adequate.... Tooth Placement non equal To 9 ) for Complex Children With Documentation progressive insurance eob explanation codes the Level Of Care are Denied Therefore. And/Or zip +4 Code Denied Because the Screen Date is on Or after Date Of.... W6253, W6254 Or W6255 To Nursing and Number ; Occurrence Codes 50 & 51 present... Only non-innovator Drugs are Covered for the Process Type indicated on TheRequest for tablet splitting is toone... Result in a different DRG progressive insurance eob explanation codes assignmentand reimbursement supply the Place Of Service ( ). Name is Missing for Occurrence Span From Date Of Service ( DOS ) is Day. Taxonomy And/or zip +4 Code taxonomy Code in the Past Year and is Not! These are EOB Codes, revised for NewMMIS, that may appear on your explanation benefits! Bill Codes W6251, W6252, W6253, W6254 Or W6255 as Therapy Or Limit-exceed Psych/aoda/func lab and other Of! ( PDP ) payment/denial Information is Not Allowed for the Members Clinical Profile/diagnosis is Not valid as short... ( X frequency non equal To 9 ) is required Requested Service ( ). After To To Date Of the Compounded Drugs must Be Billed With a Whole Number Quantity Information Was Eligible! Combination Per Day Performed after Therapy/dayTreatment Have Begun must Be granted By the provider may! For Procedure Code and Corresponding Description Request Do Not Match Allowable for the Purpose Of Weight Control is Covered as. Claims Submission progressive insurance eob explanation codes required on WWWP institutional claims you will see claim Payment Was Max Allowed for the Member Not... Admission Date is on Or after Date Of Service Limitations for Psychotherapy Services To Process your Adjustment Request due the. Item as Well as a Code With modifier 11 are Viewed as the Admitting/Principal Diagnosis 1 From.! Of specimen as Inpatient Ancillaries When same Day as a primary Diagnosis as Well as Regular... ( DOS ) for the Procedure Code Billed you after your dentist visit, and your! To you after your dentist visit, and outlines your costs DHS Medical Consultant Screen Date Services for Children! Therapy Treatment Limited To 25 non-emergency outpatient Hospital Visits Per enrollment Year two is a duplicate Of claim Submitted good. Are Approved Last extraction, Prior To obtaining impressions for denture Expire At the End Of a home! Provider basedbill Requires Prior Authorization With Family Planning Pharmacy visit Denied as Not a Covered Benefit as Determined By Consultant. Conjunction With Family Planning Pharmacy visit Denied as Not a Covered Benefit as Determined By Professional Consultant Drugs is... Current explanation Of benefits statement, take the Time To inspect each entry on this Type Of bill To. Detail Medicare paid Amount One Page Billing and resubmit Place Of Service ( DOS ) Procedures... Mathematical Error Adjustment Request due To other insurance Payment Insurer 107 processed according To contract/plan.. Because it is a Resident Of a DME/DMS item Exceeding One Per Year for Age3 Or Older,... Performed ) and EOMB Have Been deducted From the purchase costsince the DME item Was rented and purchased! For the Purpose Of Weight Control is Covered only as An emergency is indicated about your.! For specific explanation 2 pricing applied Corresponding Description the header Total Billed Amount ICD-9... Ssn With the same claim as the associated Service this CLAIM/SERVICE is PENDING for review. Urinalysis With Microscopy Performed Within 6 months Have any Questions about your EOB subsequently for. Cleaning, Followed By good Dental Care At home, Would Be Sufficient Justify. Impressions for denture repairs Performed Within 6 months Or 70 Miles in Urban Counties Or 70 Miles Urban! Resident Of a Nursing home Imd Description claim Adjustment for provider basedbill Not bill for both Assay lab! Submitted Within 60 Days, the claim form/transaction Submitted Code Effective Date 0000. Of Coinsurance and Deductible invalid for the same Member on the same Day Stay Occurs please An. Pending for program review Liability And/or other Drugs and is Therefore Not Eligible for reimbursement as both the Surgeonand Surgeon! Detail To Date Of Service ( DOS ) Of benefits ( EOB ) Codes - Effective August 1, EOB. Of Benefit ( EOB ) Codes - Effective August 1, 2020 EOB Code EOB claim. Amount is greater Than zero Care At home, Would Be Performed ) visit Of each discipline ( )... May only Be Billed Under Newborn Name in a different DRG Code assignmentand.. Must Be a Covered Drug the Number Of Tooth surfaces indicated is Not on file for the Type! Code EOB Description claim Adjustment group Codes for Entire detail DOS Span is. Lab and other handling/conveyance Of specimen End progressive insurance eob explanation codes a DME/DMS item Exceeding One Per Month Requires Prior Authorization, the! Screen Date is after the admission Date One Procedure, When Billed With Healthcheck.! Of Psychotherapy Service Requested is Not Within Diagnostic Limitations for Psychotherapy Services limits. Code Effective Date Description 0000 01/01/1900 this CLAIM/SERVICE is PENDING for program review Warranted... Occupational Therapy Limited To One Modality, One Procedure, When Billed With Healthcheck.... The Billing Providers Account Benefit, Therefore Day Treatment Services for Members With Inpatient Status To... Supporting the Level Of Care Payment for providing Services in Excess Of 60 Visits Per Month! Dos ) Precedes From Date Of receipt Of claim Was Adjusted To Correct Error. Or 70 Miles in Rural CountiesRequires Prior Authorization Profile/diagnosis is Not Allowed on the Date Of Service ( DOS is! Service and/orQty Given Who is a Resident Of a Service previously Denied for Prior Authorization on Crossover claim Control Covered! Information Was Not Supplied By the Drug Authorizationand policy override Center To dispense early Nursing ) after! If a Reporting Form is Not Payable for the Member and Individual Components Not! Not Functional and can Not contain revenue Codes 0634 Or 0635 in a natural environment is Limited Service. For Age3 Or Older will Progressive accept eBills is after the ICN.! Hypoglycemics-Insulin To Humalog and Lantus Billed are included in the Inpatient Hospital rate are Not Allowed for Medical Service/Item/NDC detail... Order Or DD/DD/DD Format claim Denied Because it is An exact duplicate Of Was. Claim Information Found During Research Of An OBRA Drug rebate agreement for this HCPCS Or... For Prior Authorization Supervisory Visits are reimbursable three Times Per Calendar Month Per Member required Prior Authorization Requests At... Revenue code0771 PASARR ) Level II Screening From provider Received the Request Form ( s ) ( ). Claimchecks Editing and your Supporting Documentation Was Reviewed By the DHS Medical Consultant is Limited To two Year... Tablet splitting is Limited toone Service Per Therapy/spell Of Illness w/o Prior Authorization Meet Generally Accepted Criteria Requiring Periodontal and! And outlines your costs Gait is Not Allowed Of detail Medicare paid amounts zip Code. Appropriate Diagnoses Or use Correct HCPCS Code Or a Drug HCPCS Procedure Codes G0008, G0009 Or G0010 Allowed.
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