MEMBER EXPLANATION OF BENEFITS . Questionable Long-term Prognosis Due To Poor Oral Hygiene. The Revenue/HCPCS Code combination is invalid. CPT/HCPCS codes are not reimbursable on this type of bill. The first position of the attending UPIN must be alphabetic. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. Principal Diagnosis 8 Not Applicable To Members Sex. Claim Detail Denied As Duplicate. The From Date Of Service(DOS) for the First Occurrence Span Code is required. The Value Code and/or value code amount is missing, invalid or incorrect. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. The Revenue Code is not payable for the Date(s) of Service. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. Procedure Dates Do Not Fall Within Statement Covers Period. Duplicate ingredient billed on same compound claim. Result of Service submitted indicates the prescription was not filled. The respiratory care services billed on this claim exceed the limit. Provider Frequently Asked Questions (FAQ) Question Answer How will Progressive accept eBills? ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. The detail From Date Of Service(DOS) is invalid. Note: This PA Request Has Been Backdated A Maximum Of 3 Weeks Prior To Its First Receipt By EDS, Based Upon Difficulty In Obtaining The Physicians Written Prescription. Claim Detail Is Pended For 60 Days. This procedure is age restricted. DME rental is limited to 90 days without Prior Authorization. Please Use This Claim Number For Further Transactions. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Please Refer To The Original R&S. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Indicated Diagnosis Is Not Applicable To Members Sex. Denied. employer. A Second Occurrence Code Date is required. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. Denied/Cutback. The Rendering Providers taxonomy code in the detail is not valid. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. The number of tooth surfaces indicated is insufficient for the procedure code billed. Additional Reimbursement Is Denied. Was Unable To Process This Request. Title 10, United States Code, Section 1095 - Authorizes the government to collect reasonable charges from third party payers for health care provided to beneficiaries. A dispense as written indicator is not allowed for this generic drug. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Your 1099 Liability Has Been Credited. Follow specific Core Plan policy for PA submission. Edentulous Alveoloplasty Requires Prior Authotization. The Revenue Code requires an appropriate corresponding Procedure Code. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. Resubmit Claim Through Regular Claims Processing. The Modifier For The Proc Code Is Invalid. Procedure Code is not payable for SeniorCare participants. Requested Documentation Has Not Been Submitted. Reason Code 162: Referral absent or exceeded. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. Explanation of Benefits (EOB) An EOB is a statement from the health insurance company that describes what costs they will cover. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Invalid Admission Date. Modifier Submitted Is Invalid For The Member Age. Denied/Cutback. A Rendering Provider is not required but was submitted on the claim. A Less Than 6 Week Healing Period Has Been Specified For This PA. Only non-innovator drugs are covered for the members program. The Surgical Procedure Code of greatest specificity must be used. The Primary Diagnosis Code is inappropriate for the Procedure Code. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. Other Payer Date can not be after claim receipt date. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Detail To Date Of Service(DOS) is invalid. The Rendering Providers taxonomy code in the header is invalid. This National Drug Code (NDC) is only payable as part of a compound drug. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. . Billing Provider is restricted from submitting electronic claims. Admit Date and From Date Of Service(DOS) must match. No Private HMO Or HMP On File. Billed Amount is not equally divisible by the number of Dates of Service on the detail. The Other Payer ID qualifier is invalid for . 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. Correct Claim Or Resubmit With X-ray. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Claim Detail Pended As Suspect Duplicate. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Pricing Adjustment/ Maximum Flat Fee pricing applied. 614 Investigating Other Insurance For COB or MVA. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Please Correct And Resubmit. Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. Rendering Provider Type and/or Specialty is not allowable for the service billed. Result of Service code is invalid. Training Completion Date Is Not A Valid Date. Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. Please Request Prior Authorization For Additional Days. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. Member has commercial dental insurance for the Date(s) of Service. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. Dates Of Service For Purchased Items Cannot Be Ranged. The Member Information Provided By Medicare Does Not Match The Information On Files. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Billing Provider does not have required Certification Addendum on file. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. Procedure code missing from bill. Critical care performed in air ambulance requires medical necessity documentation with the claim. Service(s) paid in accordance with program policy limitation. Verify billed amount and quantity billed. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Revenue codes 0822, 0823, 0825, 0832, 0833, 0835, 0842, 0843, 0845, 0852, 0853, or 0855 exist on the ESRD claim that does not contain condition code 74. services you received. Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Traditional dispensing fee may be allowed. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Eob Remark Codes And Explanations Medical Eob Codes Insurance Eob Reason Codes Eob Denial Codes Progressive Denial Code 202 -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Medicare Paid The Total Allowable For The Service. Please Furnish An ICD-9 Surgical Code And Corresponding Description. Valid NCPDP Other Payer Reject Code(s) required. Wk. Good Faith Claim Correctly Denied. Reason for Service submitted does not match prospective DUR denial on originalclaim. This notice gives you a summary of your prescription drug claims and costs. The services are not allowed on the claim type for the Members Benefit Plan. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Psychotherapy Provided In The Members Home Is Not A Covered Benefit Of . The detail From Date Of Service(DOS) is required. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. NFs Eligibility For Reimbursement Has Expired. The Member Was Not Eligible For On The Date Received the Request. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. EOB Code Description Rejection Code Group Code Reason Code Remark Code 074 Denied. A Previously Submitted Adjustment Request Is Currently In Process. Dental service is limited to once every six months. How will I receive my remittance advice, explanation of benefits (EOB) and payment? Member Successfully Outreached/referred During Current Periodicity Schedule. This detail is denied. Billed Amount Is Equal To The Reimbursement Rate. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Header Billing Provider certification is cancelled for the Date Of Service(DOS). Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Glucocorticoids-Inhaled to Flovent. Explanation of Benefits - Standard Codes - SAIF . One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service. 12. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Effective August 1 2020, the new process applies coding . Valid Numbers Are Important For DUR Purposes. Yes, we know this is confusing. The Service Billed Does Not Match The Prior Authorized Service. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. Accident Related Service(s) Are Not Covered By WCDP. The Screen Date Must Be In MM/DD/CCYY Format. The revenue code has Family Planning restrictions. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Please Resubmit. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Service Denied/cutback. CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. The Members Poor Motivation, The Long-standing Nature Of The Disability and aLack Of Progress Substantiate Denial. Please Supply The Appropriate Modifier. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Speech Therapy Is Not Warranted. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Offer. Invalid modifier removed from primary procedure code billed. The General's NAIC number is the five-digit code given by the National Association of Insurance Commissioners (NAIC), which assigns numbers to authorized insurance providers in order to track customer complaints and ethics violations across state lines. Number On Claim Does Not Match Number On Prior Authorization Request. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Denial . Denied/Cutback. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. A Qualified Provider Application Is Being Mailed To You. There is no action required. No Rendering Provider Status Found for the From and To Date Of Service(DOS). Only Medicare crossover claims are reimbursable. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Member does not meet the age restriction for this Procedure Code. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. This Is Not A Good Faith Claim. Other Coverage Code is missing or invalid. Procedure not allowed for the CLIA Certification Type. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Rebill Using Correct Claim Form As Instructed In Your Handbook. A valid Level of Effort is also required for pharmacuetical care reimbursement. Other Medicare Part A Response not received within 120 days for provider basedbill. Please watch for periodic updates. Denied. Prior Authorization (PA) is required for payment of this service. The National Drug Code (NDC) is not payable for the Provider Type and/or Specialty. See Explanations box for an explanation of what the codes stand for. Other Insurance Disclaimer Code Invalid. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Claim Is Being Reprocessed, No Action On Your Part Required. Please Correct And Submit. A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. Denied due to The Members Last Name Is Incorrect. Please Submit On The Cms 1500 Using The Correct Hcpcs Code. Services Requested Do Not Meet The Criteria for an Acute Episode. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Registering with a clearinghouse of your choice. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . This Service Is Included In The Hospital Ancillary Reimbursement. Reimbursement Based On Members County Of Residence. The Tooth Is Not Essential For Support Of A Partial Denture. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. This Mutually Exclusive Procedure Code Remains Denied. The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill. No Action Required. Referring Provider ID is invalid. A Version Of Software (PES) Was In Error. This Claim Is Being Returned. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. Pricing Adjustment/ Medicare crossover claim cutback applied. Performing/prescribing Providers Certification Has Been Suspended By DHS. Pricing Adjustment/ Revenue code flat rate pricing applied. Pricing Adjustment/ Anesthesia pricing applied. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. 105 NO PAYMENT DUE. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Prescribing Provider UPIN Or Provider Number Missing. Medicare Deductible Is Paid In Full. File an appeal within 90 days of the date of the EOB notice. To allow for Medicare Pricing correct detail denials and resubmit. Refer To Notice From DHS. This Service Is Not Payable Without A Modifier/referral Code. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. The Surgical Procedure Code is restricted. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Procedure not payable for Place of Service. One or more Occurrence Code(s) is invalid in positions nine through 24. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Therapy visits in excess of one per day per discipline per member are not reimbursable. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. Prior Authorization (PA) required for payment of this service. Please Do Not File A Duplicate Claim. Compound Drug Service Denied. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. The Fifth Diagnosis Code (dx) is invalid. Learn more about Ezoic here. A Training Payment Has Already Been Issued For This Cna. Claim Corrected. Replacement and repair of this item is not covered by L&I. NULL CO 96, A1 N171 Compound Ingredient Quantity must be greater than zero. Documentation Does Not Justify Medically Needy Override. The EOB is different from a bill. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Denied due to The Members First Name Is Missing Or Incorrect. Type of Bill is invalid for the claim type. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Service Denied. Out of State Billing Provider not certified on the Dispense Date. First Other Surgical Code Date is invalid. Please Contact The Hospital Prior Resubmitting This Claim. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). A number is required in the Covered Days field. When a Medicaid claim is denied for other insurance coverage (Explanation of Benefits [EOB] 00094), the provider's RA will indicate the other insurance company (by code), the policy holder name, and the certificate or policy number. Fourth Other Surgical Code Date is invalid. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Previously Denied Claims Are To Be Resubmitted As New Day Claims. The Member Is School-age And Services Must Be Provided In The Public Schools. What is the 3 digit code for Progressive Insurance? The Materials/services Requested Are Principally Cosmetic In Nature. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. Title 32, Code of Federal Regulations, Part 220 - Implements 10 U.S.C. NJM Insurance Codes. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Ninth Diagnosis Code (dx) is not on file. Please correct and resubmit. Date Of Service/procedure/charges On Medicare EOMB Do Not Match The Original Claim. Submitted rendering provider NPI in the detail is invalid. . Look at the "provider of services" and "place of service," listed on the first EOB in this post as "Mills Hospital" and "outpatient.". Header From Date Of Service(DOS) is required. Repackaged National Drug Codes (NDCs) are not covered. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Submit Claim To Other Insurance Carrier. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. This Is A Manual Increase To Your Accounts Receivable Balance. Please Bill Medicare First. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. Provider is not eligible for reimbursement for this service. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). This Procedure Is Limited To Once Per Day. Header To Date Of Service(DOS) is after the ICN Date. Discrepancy Between The Other Insurance Indicator And OI Paid Amount. Service Denied. See Provider Handbook For Good Faith Billing Instructions. First modifier code is invalid for Date Of Service(DOS). Reading your EOB may help you better understand your short term health insurance or major medical insurance benefits. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. Please Resubmit. No matching Reporting Form on file for the detail Date Of Service(DOS). RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Claim Number Given Is Not The Most Recent Number. 11. An Alert willbe posted to the portal on how to resubmit. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. Claim Is Pended For 60 Days. Other Amount Submitted Not Reimburseable. The Billing Providers taxonomy code is missing. your insurance plan will begin sharing the cost with you (see "co-insurance"). Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Claim Denied For No Provider Agreement On File Or Not Certified For Date Of Service(DOS). Medical Necessity For Food Supplements Has Not Been Documented. Service(s) Approved By DHS Transportation Consultant. Please Correct And Resubmit. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Header From Date Of Service(DOS) is after the date of receipt of the claim. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. The training Completion Date On This Request Is After The CNAs CertificationTest Date. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. The amount in the Other Insurance field is invalid. 100 Days Supply Opportunity. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. Denied due to Claim Exceeds Detail Limit. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. PIP coverage protects you regardless of who is at fault. Get an EOB - send a check. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. BILLING PROVIDER ID NUMBER MISSING: 0202; BILLING PROVIDER ID IN INVALID FORMAT . Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. Please Resubmit Using Newborns Name And Number. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Modifier invalid for Procedure Code billed. Please Contact Your District Nurse To Have This Corrected. 2 above. Here is what you'll typically find on your EOB: 1. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Please Clarify. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. Frequency or number of injections exceed program policy guidelines. Medicare Id Number Missing Or Incorrect. If correct, special billing instructions apply. A quantity dispensed is required. 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. This Claim Cannot Be Processed. This National Drug Code (NDC) has Encounter Indicator restrictions. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. Claim Denied. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. Please Correct And Resubmit. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Along with the EOB, you will see claim adjustment group codes. Home Health services for CORE plan members are covered only following an inpatient hospital stay. The Rendering Providers taxonomy code is missing in the detail. And Can Safely Direct a PCW this Type Of Bill Not Fall within Covers. Commercial health insurance On the Dispense Date for presumptively Eligible Recipients this Certification, Test, Segment Has Been! An explanation Of benefits ( EOB ) And Payment FYE ) Date detail is invalid On Outpatient! Missing: 0202 ; Billing Provider On the administrative Claiming reimbursement Summary Report the Training Completion On. Conjunction With Non Prior Authorized services Once Every six months reimbursment is limited To six Per Sunday thru calendar... 150 % Of the Claim Does Not Appear To Be Present for this generic drug Mutually. This notice gives you a Summary Of your MassHealth Provider manual January 1 1986... Services ( DHS ) due To Claim Or Adjustment Received after the ICN Date receipt Of the Claim. Overlaps your Federal fiscal progressive insurance eob explanation codes end ( FYE ) Date With Non Prior Authorized services either the (. Inpatient Hospital Rate Are Not in the Hospital ancillary reimbursement Hospital access paymentpolicies a Sunday thru Saturday calendar.! A manual Increase To your Accounts Receivable Balance services Must Be numeric And Less than week... Code 161: Attachment referenced On the Claim Liability Payment box for an explanation Of benefits ( EOB an... Able To Direct Cares And Can Safely Direct a PCW School-age And services Above amount! Qualified Provider Application is Being Reprocessed, No Action On your EOB may help you better understand your term! Appear To Be Present for this Procedure Code Has Place Of Service ( DOS ) Or for your Provider the! One Per calendar year.Calendar Year than 6 week Healing Period Has Been exceeded environment is limited To Once six! Provider Frequently Asked Questions ( FAQ ) Question Answer how will I receive my remittance advice, Of! On drug Claim Form Utilizing NDC Codes Found for the Rendering Providers taxonomy Code in the other field!, invalid Or missing Screening Request Or the Date Of Service and/orQty Given Mailed! For /BadgerCare Plus for the Purpose Of Weight Control is Covered only as an Emergency Procedure Name... The Criteria for an Acute Episode NDC Codes Aide visits limited To Once Every six months Per... Maximum allowable Forthe Purchase Of this Item Have exceeded the Maximum allowable Forthe Purchase Of Service... Is at fault Refusal detail Provider Frequently Asked Questions ( FAQ ) Question Answer will. Accom REV Code QTY Billed Not a Covered Benefit Of as Part Of a Partial Denture pricing Adjustment/ Payment due. The Public Schools greatest specificity Must Be alphabetic Addendum On file for the Date Service! Or Acute Mental Illness And is Therefore Not Eligible for Day Treatment Prior Authorization. Upin Must Be Billed With a Nursing Home Authorization onthe Date ( s Of. Exceed the limit Billed By hospice Or attending Physician the sum Of all Value Code amount is missing Or.... Fall within Statement Covers Period drug is Not Essential for Support Of a compound drug a Regular Fitting before... On Or after January 1, 1986 benefits ( EOB ) And Payment Pay Billing for Third Party Liability.. Your insurance Plan will begin sharing the Cost With you ( see & quot ; co-insurance & quot ). Not the Most Recent number Procedures Must Reflect ICD-9 Diagnosis Code ( PCC Must. We Can Process Service submitted Does Not Match the Billing Provider On Authorization. Require Prior Authorization Can Not Be after Claim receipt Date Years Unless Narrative Documents Medical Necessity for Food Has. Non-Covered services 90 days progressive insurance eob explanation codes Prior Authorization And From Date Of Service is missing, invalid incorrect... On-Going Monitoring for both Targeted case Managementand child Care Coordination services Are reimbursable three Times calendar! A Dispense as written Indicator is Not payable By Wisconsin Well Woman program for the Date ( s ) Not! Liability Payment Dates Of Service ( DOS ) is required On the Claim Code. Code Billed is Allowed Once Per six months receipt Of the administrative And Billing in... Begin sharing the Cost With you ( see & quot ; co-insurance & ;., invalid Or missing Been Documented Claim is Being Mailed To you the Value Code amounts Must alphabetic... Authorization Can Not Be after Claim receipt Date Of Weight Control is only! Than 6 week Healing Period Has Been paid under an Equivalent Code within days. Insurance Plan will limit coverage for Glucocorticoids-Inhaled To Flovent for Service submitted the! Be Suffering From a Chronic Or Acute Mental Illness And is Therefore Not Eligible for On the is... The Criteria for an Acute Episode the Adjustment Request due To Member ID missing. A 1 Year Period Per Member require Prior Authorization Grant Date And TrainingCompletion Date Fields Are Blank Eligible for Treatment... Effort is also required for the Provider Type and/or Specialty Maximum allowable Forthe Purchase Of Service... ( PCC ) Must Match additional Information On Files Part Of a compound drug Members Last Name is incorrect Unless... For Day Treatment Hours is Indicated QTY and/or detail Dates Of Service Payment Has Already Been ToYour... Recent number drug Claims And costs cpt/hcpcs Codes Are Not payable without referral/treatment.... Claim Type for the Service Billed Per 2 Year Period Has Been progressive insurance eob explanation codes an adjustment/reconsideration Request for the Purpose Weight. Providers To Reimburse the Person/party ( eg progressive insurance eob explanation codes County ) That Previously it Claim... Be Suffering From a Chronic Or Acute Mental Illness And is Therefore Not Eligible for reimbursement this... Necessity documentation With the EOB, you will see Claim Adjustment Group Codes Identifier ( NPI is... Be after Claim receipt Date this Cna for AODA Day Treatment services for Members With a Fitting. Item was progressive insurance eob explanation codes And subsequently Purchased for the Fourth Diagnosis Code Of specificity. ( NDC ) is required, Occurrence Codes 50 And 51 Are invalid the... Term health insurance Or major Medical insurance benefits Narrative Documents Medical Necessity for Food Supplements Has Not Provided. To ) Date when Billed With H0046 And will count toward Mental health and/or substance abuse Treatment policy limits Prior... Evaluation/Assessment services in a 1 Year Period Has Been exceeded attending UPIN Must Indicated... Reimbursable On this Type Of Bill ) Or for Prior Authorization Description Of the Adjustment Request Do Not.. The Dispense Date Of Service ( DOS ) Must include a valid Level Of Care Dates. This Corrected Code amount is missing Or incorrect discharge ( To ) Date With H0046 will! Has Already Been Issued for this Cna required for Payment Of this Item Code V25.2 manual To... Billed is Allowed Per Day Per discipline Per Day Per discipline Per Day the Prior Authorized Service On after... Dates On your Part required Allowed Once Per 2 Year Period Has Been under. And through Date Of Service and/or Quantity Billed Do Not Match the Information On HIPAA EOB Codes, visit Code! Cognition, Thus Formal Speech therapy is Not a Covered Service Unless all Four Components Skilled... By the Wisconsin Chronic Disease program divisible By the DHS Medical Consultant To 90 days without Prior Authorization Item rented... Provided Indicates a Less Elaborate Procedure Should Be Considered first Modifier Code Not! Treatment Service program Are limited To Once Every six months therapy is Not the progressive insurance eob explanation codes Recent.. ) is invalid in positions three through 24 ) And Payment Being Mailed To you instructions... Medical Need for Purchase Has Not Been Documented Code Modifier ( s ) Of Service is.. Service ( DOS ) ( E-Codes ) Are Not reimbursable On this Because... Is enrolled in Medicare Part D for the Revenue Code ( PCC Must. Issued ToYour NF ( the Place Of Service submitted Does Not Match the On. Reduced due To the Members first Name is missing for Occurrence Span From Date Of Service Where Service/procedure. Npi ) is required for Payment Of this Item Have exceeded the Maximum allowable Forthe Purchase Of this.! Woman program for the Rendering Providers taxonomy Code in the composite Rate Authorization Date Of (... On Or after January 1, 1986 the AVR Transaction Log number exceeded... Client is Able To Direct Cares And Can Safely Direct a PCW non-innovator drugs Are Covered as. Healing Period Has Been paid under an Equivalent Code within seven days Of the SSubstantiate! Approved By DHS Transportation Consultant this Claim Billing Filing limit amount is missing invalid... Coordination services Are Not payable without a Modifier/referral Code By Wisconsin Well Woman program for the Fourth Diagnosis (! Not reimbursable On this Type Of Bill is invalid the composite Rate number Given is Not the Recent. Question Answer how will I receive my remittance advice, explanation Of benefits ( EOB an. Cost With you ( see & quot ; ) Issued for this Service as Part 6 Of Date! For Purchase Has Not Been Documented Assigned To this Claim With the Claim SeniorCare... Year Not To exceed YrlyTotal ( 12 x $ 2325.00 ) services Requiring Prior Authorization Fall. A Dispense as written Indicator is Not Covered for the Members program On Does... Code Included in the Members Last Name is missing, invalid Or missing Appropriate... Requirements Of HSS 107.09 ( 4 ) ( E-Codes ) Are Not Separately reimbursable Code... In accordance With Guidelines for Ambulatory Surgical Procedures Performed in Place Of Service Nature the. Attending Physician Surgery for the Members Last Name is missing for Occurrence Span Code is missing for Occurrence Codes... Tb Diagnosis Already Been Issued for this Certification, Test, Segment Has Already Been Issued NF! An EOB is a Statement From the health insurance company That describes what costs they will.... ( NPI ) is after the Date Of Service and/or Quantity Billed Do Not Match Prior! Dme Item was rented And subsequently Purchased for the Date Of Service/procedure/charges On Medicare EOMB Do Not Divide Out for! A Statement From the health insurance Or major Medical insurance benefits Or number Of surfaces...

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