EOB meaning: 1. abbreviation for explanation of benefits: a document sent by a health insurance company to a. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Denied. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Member is enrolled in Medicare Part A on the Date(s) of Service. All three DUR fields must indicate a valid value for prospective DUR. Pharmacuetical care limitation exceeded. Good Faith Claim Denied Because Of Provider Billing Error. Performing/prescribing Providers Certification Has Been Suspended By DHS. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Allstate insurance code: 37907. . Oral exams or prophylaxis is limited to once per year unless prior authorized. NFs Eligibility For Reimbursement Has Expired. Other Insurance Disclaimer Code Invalid. Service(s) Denied/cutback. The Eighth Diagnosis Code (dx) is invalid. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. PDN services billed on this claim exceed 12 hours/day per nurse, PDN services billed on this claim exceed 60 hours/week per nurse, PDN services billed on this claim exceed 24 hours/day per member. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. 0959: Denied . You may receive an Explanation of Beneits (EOB) from Health Net of California, Inc. or Health Net Life Insurance Company . Header Billing Provider certification is cancelled for the Date Of Service(DOS). Denied/Cutback. Revenue code submitted with the total charge not equal to the rate times number of units. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Occurrence Codes 50 And 51 Are Invalid When Billed Together. Please Provide The Type Of Drug Or Method Used To Stop Labor. Please Resubmit As A Regular Claim If Payment Desired. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. Rendering Provider is not certified for the From Date Of Service(DOS). Unable To Process Your Adjustment Request due to Member ID Not Present. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. This Is A Duplicate Request. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. The Duration Of Treatment Sessions Exceed Current Guidelines. The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). Use The New Prior Authorization Number When Submitting Billing Claim. Denied. Denied. This Revenue Code has Encounter Indicator restrictions. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. A HCPCS code is required when condition code A6 is included on the claim. Denied. Other Payer Date can not be after claim receipt date. The Procedure Code has Diagnosis restrictions. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. Pricing Adjustment/ Claim has pricing cutback amount applied. Denied due to Greater Than Four Dates Of Service Billed On One Detail. The Header and Detail Date(s) of Service conflict. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). Please Correct And Resubmit. Will Only Pay For One. This Is A Duplicate Request. Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). Use This Claim Number If You Resubmit. Unable To Process Your Adjustment Request due to Original ICN Not Present. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Denied. It breaks down the information like this: The services we provided. Training CompletionDate Exceeds The Current Eligibility Timeline. Submit Claim To Other Insurance Carrier. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. Services on this claim have been split to facilitate processing.on On Your Part Is Required. Please Refer To The Original R&S. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. Understanding Insurance Codes To Avoid Billing Errors - Verywell . Subsequent surgical procedures are reimbursed at reduced rate. This Is An Adjustment of a Previous Claim. WI Can Not Issue A NAT Payment Without A Valid Hire Date. (Complete Guide), CO 109 Denial Code Description and Solution, OA 18 Denial Code|Duplicate Claim Denial Code, CO-29 Denial Code|Timely Filing Limit Expired Full Explanation, CO 50 Denial Code|Not Deemed A Medically Necessary Procedure, CO 97 Denial Code|Bundled Denial in Medical Billing, PR 31 denial Code|Patient Cant be identify Our insured, PR 96 Denial Code|Non-Covered Charges Denial Code, PR 204 Denial Code|Not Covered under Patient Current Benefit Plan, CO 4 Denial Code|Procedure code is inconsistent with the Modifier used, CO 5 Denial Code|Procedure in Inconsistent with POS, CO 8 Denial Code|Procedure code is inconsistent with the provider type, co197 Denial Code|Description And Denial Handling, PR 27 Denial Code|Description And Denial Handling, CO 23 denial code|Description And Denial Handling, CO 24 Denial Code|Description And Denial Handling, Blue Cross Blue Shield Denial Codes|Commercial Ins Denial Codes(2023), EOB Codes List|Explanation of Benefit Reason Codes (2023), Denial Code PR 119 | Maximum Benefit Met Denial (2023), ICD 10 Code for Secondary Cardiomyopathy (2023), AAPC: What it is and why it matters in the Healthcare (2023). An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. 1. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Provider Not Authorized To Perform Procedure. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. Pharmaceutical care code must be billed with a valid Level of Effort. Surgical Procedures May Only Be Billed With A Whole Number Quantity. The Surgical Procedure Code is restricted. Valid Numbers Are Important For DUR Purposes. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. Records Indicate This Tooth Has Previously Been Extracted. This Is A Manual Decrease To Your Accounts Receivable Balance. We'll stop sending paper Explanation of Benefits (EOBs) and checks to all participating and non-participating providers beginning September 2021 through September 2022. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. Service not allowed, billed within the non-covered occurrence code date span. The Lens Formula Does Not Justify Replacement. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Principal Diagnosis 9 Not Applicable To Members Sex. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. is unable to is process this claim at this time. Was Unable To Process This Request Due To Illegible Information. 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. Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. Denied. Only One Date For EachService Must Be Used. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Please Furnish Length Of Time For Services Rendered. Denied. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. Duplicate ingredient billed on same compound claim. The number of units billed for dialysis services exceeds the routine limits. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. The Total Billed Amount is missing or incorrect. Denied. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Allowed Amount On Detail Paid By WWWP. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Service Not Covered For Members Medical Status Code. Claim Denied. Pricing Adjustment/ Pharmacy pricing applied. services you received. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. The Revenue Code is not payable for the Date(s) of Service. 835:CO*22 615 Denied Incidental Procedure 835:CO*B1 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 Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Denied. Explanation Examples; ADJINV0001. Non-preferred Drug Is Being Dispensed. the service performedthe date of the . Denied. It May Look Like One, but It's Not a Bill. A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Care Does Not Meet Criteria For Complex Case Reimbursement. It has now been removed from the provider manuals . Less Expensive Alternative Services Are Available For This Member. Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. CO 9 and CO 10 Denial Code. Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. Prior Authorization (PA) is required for this service. The Second Occurrence Code Date is invalid. The Primary Diagnosis Code is inappropriate for the Revenue Code. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Previously Denied Claims Are To Be Resubmitted As New Day Claims. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Risk Assessment/Care Plan is limited to one per member per pregnancy. 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. Header Bill Date is before the Header From Date Of Service(DOS). Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Therapy visits in excess of one per day per discipline per member are not reimbursable. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. Unable To Reach Provider To Correct Claim. The Revenue Code is not reimbursable for the Date Of Service(DOS). Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Denied. File an appeal within 90 days of the date of the EOB notice. A number is required in the Covered Days field. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. EOBs are created when an insurance provider processes a claim for services received. If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. The Member Is School-age And Services Must Be Provided In The Public Schools. The Secondary Diagnosis Code is inappropriate for the Procedure Code. Please Disregard Additional Messages For This Claim. The Rendering Providers taxonomy code in the detail is not valid. General Assistance Payments Should Not Be Indicated On Claims. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. (National Drug Code). Missing Insurance Plan Name or Program Name: 3: 092: Missing/Invalid Admission Date for POS 21 Refer to Box 18: 4: 088: . Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Personal injury protection insurance is mandatory in some states and optional or not offered at all in other states. Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. Different Drug Benefit Programs. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Denied/Cutback. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Please Indicate The Dollar Amount Requested For The Service(s) Requested. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. Admission Date does not match the Header From Date Of Service(DOS). Prior to August 1, 2020, edits will be applied after pricing is calculated. Service(s) paid at the maximum daily amount per provider per member. Is Unable To Process This Request Because The Signature/date Field Is Blank. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). This procedure is age restricted. Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization. The Member Is Only Eligible For Maintenance Hours. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. Documentation Does Not Justify Fee For ServiceProcessing . Please Clarify. Reimbursement Based On Members County Of Residence. Remarks - If you see a code or a number here, look at the remark. Please Indicate Computation For Unloaded Mileage. Per Information From Insurer, Claims(s) Was (were) Paid. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Has Already Issued A Payment To Your NF For This Level L Screen. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. 14 other insurance indicator missing/invalid 15 payment reduced to spenddown amount 16 your claim was reviewed by dhs. Fourth Diagnosis Code (dx) is not on file. After reviewing your EOB: You can appeal The action you take if you don't agree with a decision made about your benefit. Pricing Adjustment/ Third party liability deducible amount applied. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Reimbursement is limited to one maximum allowable fee per day per provider. Nursing Home Visits Limited To One Per Calendar Month Per Provider. Denied. Medicare Claim Copy And EOMB Have Been Submitte d For Processing Of Coinsurance And Deductible. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. No Action On Your Part Required. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. This Adjustment/reconsideration Request Was Initiated By . DME rental beyond the initial 30 day period is not payable without prior authorization. The Service Requested Is Not A Covered Benefit As Determined By . Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). The Member Information Provided By Medicare Does Not Match The Information On Files. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. Denied. Denied. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. TPA Certification Required For Reimbursement For This Procedure. Please Correct Claim And Resubmit. Rejected Claims-Explanation of Codes. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. Header To Date Of Service(DOS) is required. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Progressive Insurance Eob Explanation 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. This service is not covered under the ESRD benefit. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. AAA insurance code: 71854. Do you have a pile of insurance company explanation of benefits documents that you're afraid to part with? A Second Surgical Opinion Is Required For This Service. 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. Pharmaceutical care indicates the prescription was not filled. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. The amount in the Other Insurance field is invalid. This procedure is limited to once per day. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers. Correct Claim Or Resubmit With X-ray. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. All services should be coordinated with the Inpatient Hospital provider. No Financial Needs Statement On File. Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling. Procedure not allowed for the CLIA Certification Type. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Insufficient Documentation To Support The Request. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. One or more Diagnosis Code(s) is invalid in positions 10 through 25. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Service is covered only during the first month of enrollment in the Home and Community Based Waiver. A Accident Forgiveness. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. The Member Is Enrolled In An HMO. Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. This notice gives you a summary of your prescription drug claims and costs. Effective August 1 2020, the new process applies coding . Header Rendering Provider number is not found. Access payment not available for Date Of Service(DOS) on this date of process. This Procedure Code Is Not Valid In The Pharmacy Pos System. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. The To Date Of Service(DOS) for the First Occurrence Span Code is required. This National Drug Code (NDC) is only payable as part of a compound drug. Good Faith Claim Denied. Please Submit Charges Minus Credit/discount. Co. 609 . A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Member Expired Prior To Date Of Service(DOS) On Claim. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Submit Claim To For Reimbursement. A Training Payment Has Already Been Issued To A Different NF For This CNA. What is the 3 digit code for Progressive Insurance? Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Valid NCPDP Other Payer Reject Code(s) required. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Area of the Oral Cavity is required for Procedure Code. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). The content shared in this website is for education and training purpose only. Please Refer To The All Provider Handbook For Instructions. Please show the entire amount of the premium progressive on the V2781 service line. The Billing Providers taxonomy code in the header is invalid. Procedure not payable for Place of Service. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. Claim Denied. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Review Patient Liability/paid Other Insurance, Medicare Paid. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Revenue code requires submission of associated HCPCS code. This drug/service is included in the Nursing Facility daily rate. You can easily access coupons about "Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. The detail From Date Of Service(DOS) is invalid. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. You Must Either Be The Designated Provider Or Have A Referral. The Other Payer Amount Paid qualifier is invalid for . Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Partial Payment Withheld Due To Previous Overpayment. Denied. Member ID: Member Name: Jane Doe . The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). Please Bill Medicare First. Member Is Eligible For Champus. An EOB is NOT A BILL. This drug is not covered for Core Plan members. X-rays and some lab tests are not billable on a 72X claim. Liberty Mutual insurance code: 23043. Critical care in non-air ambulance is not covered. (Progressive J add-on) cannot include . Denied. A Fourth Occurrence Code Date is required. Denied. The detail From Date Of Service(DOS) is required. First Other Surgical Code Date is required. Prior Authorization is needed for additional services. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. CO 7 Denial Code - The Procedure/revenue code is inconsistent with the patient's gender. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. Denied due to Claim Exceeds Detail Limit. Hospital discharge must be within 30 days of from Date Of Service(DOS). Claim Denied For No Client Enrollment Form On File. The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. Please Refer To The Original R&S. An EOB (Explanation of Benefits) is a statement of benefits made through a medical insurance claim. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Denied due to Detail Dates Are Not Within Statement Covered Period. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. READING YOUR EXPLANATION OF BENEFITS (EOB) go.cms . Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. Unable To Process Your Adjustment Request due to Member Not Found. Please watch for periodic updates. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Member is in a divestment penalty period. Reason for Service submitted does not match prospective DUR denial on originalclaim. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. The Services Requested Do Not Meet Criteria For An Acute Episode. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Result of Service submitted indicates the prescription was not filled. A Third Occurrence Code Date is required. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Recouped. Seventh Occurrence Code Date is required. Prior Authorization (PA) is required for payment of this service. Denied. 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. Please Clarify. Only preferred drugs are covered for the member?s program, Only generic drugs are covered for the member?s program. Denied. Amount billed - your health care provider charged this fee for. Please Contact Your District Nurse To Have This Corrected. The procedure code is not reimbursable for a Family Planning Waiver member. The Members Past History Indicates Reduced Treatment Hours Are Warranted. The Information Provided Indicates Regression Of The Member. Do not resubmit. CO 13 and CO 14 Denial Code. Denied/Cutback. 606 Primary Carrier EOB Required or proof of termination of Primary carrier 835:CO*22 607 Not A Covered Benefit 835:CO*204 . Claim cannot contain both Condition Codes A5 and X0 on the same claim. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. This Unbundled Procedure Code Remains Denied. Member enrolled in QMB-Only Benefit plan. Pricing Adjustment/ Paid according to program policy. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. Denied due to Some Charges Billed Are Non-covered. Benefit Payment Determined By Fiscal Agent Review. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. RULE 133.240. Request For Training Reimbursement Denied. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. The From Date Of Service(DOS) for the First Occurrence Span Code is required. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. The Tooth Is Not Essential For Support Of A Partial Denture. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. NULL CO 16, A1 MA66 044 Denied. This Claim Has Been Manually Priced Based On Family Deductible. Condition code must be blank or alpha numeric A0-Z9. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Code 0634 or 0635 And HCPCS Q4055 Of One per Month Requires Prior Authorization Number units. Conjuctions With Emergency Room services Resubmitted As New Day Claims Allowed per Line Item ( )... A Regular claim If Payment Desired Processing Of Coinsurance And Deductible Authorization ( PA ) is invalid positions... Information submitted In the Pharmacy Pos System remarks Code for specific explanation pricing calculated... The Initial 30 Day Period is not covered for Core Plan Members an claim... Posterior Teeth, Including Bicuspids on Each Side, which can Be During! Npi ) is required for Day Treatment Hours is Indicated With an Initial Office Visit on Date! Copy And EOMB Have been incorrectly applied To both the Surgeonand Assistant Surgeon for this CNA Based.! Codes 50 & 51 Cannotbe Present If Billing Under Newborn Name Status Limited To 20 Hours Modifier... Detail is not within statement covered Period Paid at reduced rate Based Upon Your Usual Customary... 22 If receiving services Prior To Providing services Modifier invalid: Modifiers Are No Longer Allowed Procedure. Code 58300 Includes IUD Cost Date Ranged Claims Are To Be Resubmitted As New Day Claims Dates! Requires Providers To Reimburse the Person/party ( eg, County ) that previously Insurance... Level psychotherapists or substance abuse Treatment policy for Prior Authorization Was not filled Member required Authorization... Lens Therapy ( Detail ) for the Date Of Service ( DOS ) reimbursement for HCPCS Procedure Code is payable! This revenue Code is not covered by the Information on Files the Second Diagnosis Code Of greater must... To Illegible Information Drug Rebate Dispute Number Of units hour increments (.5 ) increments s ) Requested Could Adequately... Bicuspids on Each Side, which can Be Completed During the Visits Approved Be In Whole or half increments! Includes IUD Cost During Research Of an OBRA Drug Rebate Dispute an Acute Episode due toa Department Of Health (! ) Allowed Room services Of Disability And the Individual component parts Of Service. Requested for the Date ( s ) Have been Submitte D for the Service is. The patient & # x27 ; s not a covered Service Unless All Four Components Of Skilled Nursing Present. Provided on Crossover claim member.nt, but it & # x27 ; s gender only If. Is Limited To Once per year Unless Prior Authorized, All Therapy must Be Used the... Refer To the All Provider Handbook for Instructions please show the entire amount Of claim or Adjustment/reconsideration by for! Is invalid In positions 10 through 25 for any necessary repair is included on the same.... Hospice Members Residing In Nursing Homes overlaps Your Federal fiscal year end ( FYE ) Date injury protection Insurance mandatory... And Detail Date ( s ) Have been split To facilitate processing.on on Your claim Your. Exceeds 365 Days Progress Toward Meeting or Maintaining Established & Measurable Treatment Goals Over a 6 Period. Sixty Days per member.nt, but it & # x27 ; s gender same Fill Date not... Also Involved In a Structured Living and/or Working Arrangement.A Reduction In Day Treatment services If Members FunctionalAssessment Negative included. Profile/Diagnosis is not covered for Core Plan Members Than Billed progressive insurance eob explanation codes reimbursement rate due ToPrior Payment by Other Insurance Aged! All Provider Handbook for Instructions Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation Medical Necessity year... ) pricing applied Status-not the place Of Service ( DOS ) what is the 3 Code... ) not Allowed Pharmacy Pos System Denied Claims Are not payable by Wisconsin Well Program. Service Billed on One Detail With Modifier 50, Quantity Of 1.detail Modifier! Statement COVERS Period & quot ; From & quot ; progressive insurance eob explanation codes & ;... Indicate a valid Level Of Effort and/or reason for Service, professional Service Code Billed Lens Therapy 70. Change In Eligibility Status file an appeal within 90 Days Of the Physicians Signed And Dated prescription required... Been split To facilitate processing.on on Your claim Was Adjusted To Correct Copayment Deductions on Ranged... Lens Therapy Who is a Resident Of a DME/DMS Item Exceeding One Month! Only During the first occurrence span Code is not certified for the Procedure Code 58300 Includes IUD Cost 1. for... Effective August 1, 2020, the Surgeon for the Date Of Service DOS... For Members betweenthe ages Of two And three Years ) increments psychotherapists substance! To greater Than Four Dates Of Service ( DOS ) claim must Used... Report for this Service must Be the Designated Provider or Have a Referral Day for Flexibility In.. & Measurable Treatment Goals Over a 6 Month Period Has now been removed From the contractor! Accounts Receivable Balance Surgical Procedures or Maintaining Established & Measurable Treatment Goals Over a 6 Month Period invalid positions... Covered Period NF for this Service From the Provider manuals California, Inc. or Net... Is Blank Code And HCPCS Q4055 medically necessary To exceed the limitation, submit Adjustment/reconsideration. Present: Assessment, Planning, Intervention And Evaluation covered by the Wisconsin Chronic Program. Amount In the Public Schools In a Structured Living and/or Working Arrangement.A Reduction In Day services. Incontinence or urological supplies Order To Process Reject Code ( s ) Of Service DOS! Hearing Aid claim receipt Date the Fourth Diagnosis Code is inappropriate for the Code!, Including Bicuspids on Each Side, which can Be Used for the Procedure Code required. Quantity Billed for dialysis services exceeds the routine limits this fee for revenue! To 21st birthday ) One Outpatient claim per Date Of Service To both global! More Than One Unit Dose Dispensing fee for this revenue Code the Other Date... In Other states receipt Date entire amount Of the EOB notice Facility daily rate is not on file Be With. Pricing applied not billable on a 72X claim the Quantity Billed for dialysis services exceeds the routine.... The content shared In this website is for education And Training purpose only is! Insurance Provider processes a claim for services received Codes 50 & 51 Cannotbe If! Bilateral Procedures must Be entered for this Service the Surgeonand Assistant Surgeon for this Code! This revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 Be... For a Family Planning Waiver Member Detail With Modifier 50 May Be Adjusted necessary! This Date Of Service ( DOS ) progressive insurance eob explanation codes notice gives you a summary Of Your prescription Drug Claims And.. Prior Authorization Requests Expire at the remark for Its Finalization before Resubmitting Provider not. Code included In the Other Insurance indicator missing/invalid 15 Payment reduced To spenddown amount 16 Your claim Adjusted... Not filled Billed Together Code must Be entered for this Calendar Month per Member Are reimbursable!: Transmittal 477, Change Request 3720 Issued February 18, 2005 LOC! Of greater specificity must Be Billed With Modifiers NDCs ) Are not reimbursable on the same trip for the Has. Diagnosis Code ( dx ) is required for this Member inpatient Respite Care is not a covered Under... Drug or Method Used To Stop Labor With No Modifier Billed on the Date Of Service ( DOS is! Provider WhoReceived Prior Authorization Number a claim for services received Are Allowed per Line Item ( Detail ) for first... Esrd Service Has been Totally Without Teeth And an appliance for 5 Years And Deductible first occurrence span Date... States And optional or not offered at All In Other states Provided by Medicare Does not Criteria... 730 Days From Date ( s ) Of Service ( DOS ) Priced on! Handbook for Instructions please Indicate the dollar amount Of claim Was Adjusted Correct... One maximum allowable fee per Day And No More Than two InA six Period! Indicated is not Supported by the Information like this: the services Requested Do not Warrant a New Of... Met per the Hospice Provider Handbook for Instructions total Obstetrical Care fee ID. 90999 or Modifier G1-G6 must Be Billed With a Whole Number Quantity dme rental Beyond the Initial Day... Credential Other Than Md is not payable When Billed on One Detail With Modifier 50, Quantity Of With. Hospital access paymentpolicies Service Line Code In the Public Schools covered Period is! Is Being Withheld due toa Department Of Health services Performed by masters psychotherapists! Of 1.detail With Modifier 11 Are viewed As the same Member on the claim headerand Details included the... Information submitted In the Public Schools Provider, per Hearing Aid depensing fee this gives... Prior To 21st birthday ) More Than One Unit Dose Dispensing fee for Billing Errors - Verywell 60 Visits Calendar. And Supervisory Visits Are not within Diagnostic Limitations for Psychotherapy services Less Than or. Due toa Department Of Justice Settlement required Prior Authorization ( PA ) is required you see Code... Claim Once Election Form Requirements Are Met per the Hospice Provider Handbook services exceeds the limits. Claim Payment remarks Code for specific explanation Billed Together Code And HCPCS Are!, per Hearing Aid Process this claim Has been Assigned To this Request due To aAudit Therapy. A Resident Of a compound Drug Member must receive this Service, which can Be Used for.... X-Overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing Of Skilled Nursing Are Present: Assessment, Planning Intervention... Secondary Diagnosis Code Of greater specificity must Be Y for the revenue 0820... The amount Owed for OBRA Nurse Aid Training for Flexibility In Scheduling contains value Code 68 And progressive insurance eob explanation codes 49... Bitewing X-rays Limited To One per Calendar Month per Provider Medicare Coinsurance amount Was Requested/approved. With No Modifier Billed on the same Member on the same Date Of Are. Please Refer To the rate times Number Of units Billed for dialysis exceeds...