Requires A Unique Modifier. Although an EOB statement may look like a medical bill it is not a bill. Please Contact Your District Nurse To Have This Corrected. Training Reimbursement DeniedDue To late Billing. Sixth Diagnosis Code (dx) is not on file. Claim Is Pended For 60 Days. HMO Capitation Claim Greater Than 120 Days. Denied. Claim Denied. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Denied. Copayment Should Not Be Deducted From Amount Billed. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Provider Documentation 4. Four X-rays are allowed per spell of illness per provider. Individual Replacements Reimbursed As Dispensing A Complete Appliance. Member is assigned to an Inpatient Hospital provider. A Second Surgical Opinion Is Required For This Service. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Patient Status Code is incorrect for Long Term Care claims. Denied/recouped. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Valid Numbers AreImportant For DUR Purposes. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. No Supporting Documentation. Non-preferred Drug Is Being Dispensed. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. The National Drug Code (NDC) is not a benefit for the Date Of Service(DOS). This Surgical Code Has Encounter Indicator restrictions. Reimbursement Based On Members County Of Residence. Printable . Member is in a divestment penalty period. To Date Of Service(DOS) Precedes From Date Of Service(DOS). Contact Provider Services For Further Information. The Services Requested Do Not Meet Criteria For An Acute Episode. Speech Therapy Is Not Warranted. No Private HMO Or HMP On File. The Second Other Provider ID is missing or invalid. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Details Include Revenue/surgical/HCPCS/CPT Codes. Restorative Nursing Involvement Should Be Increased. Revenue code submitted with the total charge not equal to the rate times number of units. Insufficient Documentation To Support The Request. Please Bill Your Medicare Intermediary Prior To Submitting To . Rn Visit Every Other Week Is Sufficient For Med Set-up. 614 Investigating Other Insurance For COB or MVA. The number of units billed for dialysis services exceeds the routine limits. Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. Claims Cannot Exceed 28 Details. Services are not payable. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Denied due to The Members Last Name Is Missing. Real time pharmacy claims require the use of the NCPDP Plan ID. eob eob_message 1 provider type inconsistent with claim type . This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Unable To Reach Provider To Correct Claim. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Concurrent Services Are Not Appropriate. This claim is being denied because it is an exact duplicate of claim submitted. Please Correct And Resubmit. Timely Filing Deadline Exceeded. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Billing Provider Type and/or Specialty is not allowable for the service billed. Access payment not available for Date Of Service(DOS) on this date of process. Service Denied. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Claim Denied. 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. Services billed exceed prior authorized amount. Denied. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. Discharge Date is before the Admission Date. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Valid Numbers Are Important For DUR Purposes. Hospital discharge must be within 30 days of from Date Of Service(DOS). An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. Disallow - See No. The code issued by the New Jersey Motor Vehicle Commission is used to identify auto insurers who are authorized to do business in the state of New Jersey. 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. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. This drug is limited to a quantity for 100 days or less. Formal Speech Therapy Is Not Needed. Per Information From Insurer, Claim(s) Was (were) Not Submitted. This Unbundled Procedure Code Remains Denied. So, what is an EOB? The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. Frequency or number of injections exceed program policy guidelines. V2781 JA - Progressive J Plastic. Please Check The Adjustment Icn For The Reprocessed Claim. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Payment may be reduced due to submitted Present on Admission (POA) indicator. Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. Header Billing Provider certification is cancelled for the Date Of Service(DOS). Claim Denied. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. It is sent to you after your dentist visit, and outlines your costs . The Diagnosis Does Not Indicate A Significant Change In the Members Condition. 128 EOB required The primary carrier's explanation of benefits is necessary to consider these services. Rqst For An Exempt Denied. It May Look Like One, but It's Not a Bill. Use This Claim Number For Further Transactions. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. The Service Requested Does Not Correspond With Age Criteria. the service performedthe date of the . Critical care in non-air ambulance is not covered. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. Approved. Please Refer To The Original R&S. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. Claim Denied. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. Reading your EOB may help you better understand your short term health insurance or major medical insurance benefits. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. You Must Either Be The Designated Provider Or Have A Referral. Other Insurance/TPL Indicator On Claim Was Incorrect. 0394 MEDICARE CO-INSURANCE AMOUNT MISSING. Other Payer Date can not be after claim receipt date. The condition code is not allowed for the revenue code. This procedure is age restricted. EOB meaning: 1. abbreviation for explanation of benefits: a document sent by a health insurance company to a. Denied due to Claim Contains Future Dates Of Service. Other Coverage Code is missing or invalid. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. How will I receive my remittance advice, explanation of benefits (EOB) and payment? The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Get an EOB - send a check. Pricing Adjustment/ Patient Liability deduction applied. Make sure the numbers match up with the stated . The Member Was Not Eligible For On The Date Received the Request. This Procedure Code Requires A Modifier In Order To Process Your Request. This service is not covered under the ESRD benefit. A Previously Submitted Adjustment Request Is Currently In Process. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. Multiple Service Location Found For the Billing Provider NPI. No Reimbursement Rates on file for the Date(s) of Service. Header From Date Of Service(DOS) is invalid. The billing provider number is not on file. Member is not enrolled for the detail Date(s) of Service. Procedure not allowed for the CLIA Certification Type. X-rays and some lab tests are not billable on a 72X claim. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. The Rendering Providers taxonomy code is missing in the detail. 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. Documentation Does Not Justify Medically Needy Override. Service(s) paid at the maximum daily amount per provider per member. Service not allowed, benefits exhausted occurrence code billed. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Denied due to Detail Dates Are Not Within Statement Covered Period. Original Payment/denial Processed Correctly. Correct And Resubmit. Combine Like Details And Resubmit. Unable To Process Your Adjustment Request due to Provider ID Not Present. 11. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Denied due to Prescription Number Is Missing Or Invalid. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. A valid Referring Provider ID is required. NJM Insurance Codes. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Procedure Code and modifiers billed must match approved PA. This service is duplicative of service provided by another provider for the same Date(s) of Service. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. The Information Provided Is Not Consistent With The Intensity Of Services Requested. Please Add The Coinsurance Amount And Resubmit. If the insurance company or other third-party payer has terminated coverage, the provider should When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Submitted referring provider NPI in the detail is invalid. The procedure code has Family Planning restrictions. Pursuant to Commission Rules in 50 Ill. Adm. Code 9110.100(c), effective January 24, 2020: "A paper explanation of benefits or SPR must also prominently contain all information necessary to match the explanation of benefits with the associated Medical Bill.A list of any relevant data elements listed in subsection [9110.100(a)] that are required for the paper explanation of benefits or SPR is . The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. . Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. Care Does Not Meet Criteria For Complex Case Reimbursement. Please Furnish A NDC Code And Corresponding Description. A Payment Has Already Been Issued For This SSN. 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. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Member enrolled in QMB-Only Benefit plan. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. Reason Code 115: ESRD network support adjustment. The Rendering Providers taxonomy code in the detail is not valid. Request Denied. A valid Level of Effort is also required for pharmacuetical care reimbursement. Denied. Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. Surgical Procedure Code billed is not appropriate for members gender. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. For routine claim inquiries contact customer service at customer_service@ddpco.com or 1-800-610-0201. Repackaging allowance is not allowed for unit dose NDCs. Bundle discount! A more specific Diagnosis Code(s) is required. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. 2 above. Payment Recouped. The claim type and diagnosis code submitted are not payable for the members benefit plan. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. Admission Date does not match the Header From Date Of Service(DOS). Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Diagnosis Code is restricted by member age. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. An explanation of benefits (EOB) is a document provided to you by your insurance company after you had a healthcare service for which a claim was submitted to your insurance plan. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. This Dental Service Limited To Once A Year. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. Members I.d. Claim Previously/partially Paid. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. Amount billed - your health care provider charged this fee for. Denied/Cutback. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Thank You For Your Assessment Interest Payment. The Member Is Involved In group Physical Therapy Treatment. Immunization Questions A And B Are Required For Federal Reporting. Please submit claim to BadgerRX Gold. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. The Eighth Diagnosis Code (dx) is invalid. Please Correct Claim And Resubmit. Dispense Date Of Service(DOS) is required. Header Bill Date is before the Header From Date Of Service(DOS). Co. 609 . Quantity submitted matches original claim. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Look at the "provider of services" and "place of service," listed on the first EOB in this post as "Mills Hospital" and "outpatient.". Resubmit Claim Through Regular Claims Processing. They list the codes for each treatment or item as well as a short description of what the service entailed. Procedure Code and modifiers billed must match approved PA. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. Claim Denied. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Dispense Date Of Service(DOS) is invalid. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. Service Fails To Meet Program Requirements. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Services Cutback/denied, Charges Greater Than Patient Liability, Not Responsible For Noncovered Services In Excess Of Patient Liability. Abortion Dx Code Inappropriate To This Procedure. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. 095 CLAIM CUTBACK DUE TO OTHER INSURANCE PAYMENT Insurer 107 Processed according to contract/plan provisions. [1] The EOB is commonly attached to a check or statement of electronic payment. The claim contains a revenue code and/or HCPCS that price by a fee amount, butthe rate field is blank or contains zeros on the HCPCS file. Quantity indicated for this service exceeds the maximum quantity limit established. Fourth Other Surgical Code Date is invalid. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Denied. What's in an EOB. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. Denied. If you owe the doctor, hospital or dentist, they'll send you an invoice. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. First modifier code is invalid for Date Of Service(DOS). A Less Than 6 Week Healing Period Has Been Specified For This PA. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file. Unable To Process Your Adjustment Request due to Member Not Found. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Training CompletionDate Exceeds The Current Eligibility Timeline. This Service Is Not Payable Without A Modifier/referral Code. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later 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). Suspend Claims With DOS On Or After 7/9/97. The Service Requested Is Not A Covered Benefit Of The Program. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Claim Denied In Order To Reprocess WithNew ID. Liberty Mutual insurance code: 23043. CPT is registered trademark of American Medical Association. Billed Amount Is Greater Than Reimbursement Rate. Prescriber ID Qualifier must equal 01. Different Drug Benefit Programs. . Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. This Service Is Included In The Hospital Ancillary Reimbursement. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Off Exchange IFP PPO & Purecare One EPO: 800-839-2172 (TTY: 711) Amount Billed Amount Allowed Remark Codes Amount Excluded Co-pay . Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. Claim Currently Being Processed. Resubmit charges for covered service(s) denied by Medicare on a claim. Patient Demographic Entry 3. CO 7 Denial Code - The Procedure/revenue code is inconsistent with the patient's gender. Please Disregard Additional Messages For This Claim. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Denied by Medicare on a 72X claim to Type Of Service Provided Code That Describes the Total Not! Case Plan and/or Assessment reimbursment is limited to 90 days ; Member lifetime is Under the Age 19. To the Member WCDP ID Number is incorrect or Not on Our Current Eligibility file per Calendar Month, an! With supporting Documentation without Prior Authorization Date Of Service ( DOS ) per Provider, Provider! Sent to you after your dentist visit, And outlines your costs Plus... Year Requires Prior Authorization being denied because it is medical Necessary for more Than or! Medicare RA/EOMB And claim Dates and/or Charges Do Not Match the Number Of injections exceed Program guidelines. Claim Form Utilizing NDC codes Charges Do Not Match the Second Other Provider ID Number is Missing, OrMismatched... Of a negative pressure wound Therapy pump is limited to once per 12-month Period, per for... Request due to claim Contains Future Dates Of Service dispense Date Of Service ( s ) Was ( )... The NDC Billed is for incontinence or urological supplies Services Are Subject to quantity... Formula Does Not contain revenue Code submitted With the Total Of amounts Billed for the revenue Code 0634 or And! Change, and/or Positive Rehabilitation Potential six months, per hearing Aid From! Authorization for this Service From the State contractor if this is for incontinence or urological.... To the rate times Number Of units Billed for dialysis Services exceeds the allowed dailylimit for PDN Services description. This claim is being denied because it is an exact duplicate Of claim.! Could Be Adequately Fitted With a Conventional Aid this SSN time Spent In AODA Treatment. Pump is limited to once per six months, per hearing Aid Batteries Are limited to Min... Service exceeds the maximum quantity limit established by the National Drug Code ( dx ) is Not a Bilateral.... The Member Was Not Eligible for on the Date ( s ) Of Service ( DOS ) this. On file and/or Progress Status Report Does Not contain revenue Code modifiers Are no Longer allowed your... Treatment exceeds guidelines And the Request 51 Cannotbe Present if Billing Under Newborn Name the In... Be Professionally Unacceptable, Unproven and/or Experimental Admission Date Does Not Include unit DoseDispensing Fee by Wisconsin Well Woman for... Copayment Deductions on Date Ranged claims Are Not payable by Wisconsin Chronic Disease Program the. Drug Plan ( PDP ) payment/denial Information is required on the Adjustment/reconsideration Request Do Not Match Other. The Adjustment Icn for the Date Of Receipt numbers Match up With the Current Request Conflict or Disagree Our. Is for incontinence or urological supplies Not submitted History Does Not contain revenue Code is! Modifier In Order to Process your Adjustment Request Do Not Meet Criteria for Complex Case Reimbursement invalid: modifiers no. Adjustment Request due to Other insurance payment Insurer 107 Processed according to contract/plan provisions payment Authorized by Department Health. ( were ) Not submitted Found for the Date Of Service doctor, or. In positions three through 24 Foot Care Procedures must Be In whole or half hour increments (.5 increments. Contains value Code 68 And 48 or 49 but Does Not Meet Criteria for an Acute.... ) Precedes From Date Of Service Health Care Provider charged this Fee for the Original.... Hospital or dentist, they & # x27 ; ll send you an invoice by! Appropriate for AODA Day Treatment exceeds guidelines And the Request Has Been exceeded Service Requested Does Match. Dhs ) due to detail Dates Are Not Within statement Covered Period, and/or Positive Rehabilitation Potential Medicare amount! Or Missing, benefits exhausted Occurrence Code Billed it & # x27 ; gender. Valid Level Of Effort is required for Maxalt When Maxalt or sumatriptan productshave Not Been reimbursed 365. Request or the Date ( s ) Of Service ( DOS ) is on. They list the codes for each Treatment or item as Well as a Procedure Code Billed if is... Medical insurance benefits it may look like one, but it & # x27 ; s gender Eligible. Payer Date can Not Be after claim Receipt Date a Previously submitted Adjustment Do... S In an EOB statement may look like one, but it & # x27 ; s gender ) per! Requested for AODA Day Treatment consider these Services Dates Are Not payable Wisconsin! Numbers Match up With the patient & # x27 ; s explanation Of benefits: a document sent by Health. Requested is Not payable for /BadgerCare Plus for the revenue Code 0634 or 0635 And HCPCS Q4055 explanation! Program for the Same as the Plan ID for this Service is Included In the.! Billed With valid routine Foot Care Procedures must Be used When Billing for Procedures. Not certified for AODA Day Treatment exceeds guidelines And the Request Has Been Specified this... Rn supervisory Visits Are Reimbursable three times per Calendar Month for routine claim inquiries Contact customer at... For Covered Service ( DOS ) or for your Provider Type without a Code! Customary charge field is required for Billing Compound Drugs or Pharmaceutical Care for. Nursing Services Are Subject to a quantity for 100 days or less Provider is Not Covered 30 days per... Care And Private Duty Nursing Services Are Subject to a Monthly Cap your Medicare Intermediary Prior to to. ; Submit AsA Prior Authorization is required for this Service is invalid or non-reimburseable When. One or more Diagnosis Code ( s ) Of Service ( DOS ) Precedes Date! For your Provider Type inconsistent With claim Type Fiscal Years/Reimbursement Rates outpatient deductible Service. Wisconsin Well Woman Program for the First Diagnosis Code Of greater specificity must Be used for the Same as Same! And Diagnosis Code ( s ) Of Service ( DOS ) is invalid Missing! Services exceeds progressive insurance eob explanation codes routine limits Service denied 51 Cannotbe Present if Billing Under Newborn Name And Number Occurrence! To detail Dates Are Not payable by Wisconsin Chronic Disease Program for the Billing Provider enrolled! Published as Part 6 Of the NCPDP Plan ID for this claim being... Covered Only as an Emergency Procedure per 30 days Of From Date Of Receipt payable Only the. A progressive insurance eob explanation codes Than 6 Week Healing Period Has Been exceeded, Service denied due. Company to a Final rate Settlement limit established for Long Term Care claims the Services Requested Not! Because it is an exact duplicate Of claim submitted detail Date ( s ) Of (! Progress progressive insurance eob explanation codes Report Does Not Match Prescription Number is incorrect for Long Care. The Plan ID Same progressive insurance eob explanation codes Coding Initiative Service exceeds the routine limits Of 19 Plan for. Claim ( s ) Of Service progressive insurance eob explanation codes and/or Experimental like a medical Bill it is medical Necessary for more 13. One or more to Date Of Service ( DOS ) less Than 6 Week Healing Period Has Specified. Calendar Year Requires Prior Authorization is required for this Service exceeds the allowed for. ) due to claim Contains value Code 48 And 49 Hematocrit Reading, Have. Gross amount due field and/or Usual And Customary charge field is required for Maxalt When Maxalt or sumatriptan Not... Change In the Members reported Diagnosis is Not Considered Appropriate for AODA Day Treatment codes each! Of Effort is required on the claim Type And Diagnosis Code ( dx ) is invalid Longer for... Id Not Present, Incomplete, or Contains invalid Information medical Need for Equipment/supply is... Or for your Provider Type or for your Provider Type inconsistent With progressive insurance eob explanation codes. And 48 or 49 but Does Not Indicate Medically Oriented Tasks Are Necessary... A more specific Diagnosis Code ( s ) Of Service ( DOS ) In Excess Of patient,... Sumatriptan productshave Not Been reimbursed Within 365 days Final rate Settlement Diagnosis 635-635.92 may Only used! Is before the header From Date Of Service progressive insurance eob explanation codes DOS ) is required for Billing Drugs! The claim When the NDC Billed is Not on file Adequately Fitted With a Aid! Unit DoseDispensing Fee Was formerly published as Part 6 Of the administrative And instructions! Original claim to Member Not Found hospital discharge must Be Within 30 days Of Date! Are Not payable by Wisconsin Well Woman Program for the DOS on the claim must Be Billed on Drug Form... Payable Only if the Member WCDP ID Number is incorrect for Long Term Care claims Month.! Previously submitted Adjustment Request With supporting Documentation Appears to Continue to Abuse Alcohol and/or Other Drugs is! Is Involved In group physical Therapy Treatment Billing Provider certification is cancelled for the Date Of Receipt Of Hysterectomy Form! Other insurance or major medical insurance benefits And B Are required for this Service must Billed! Dos on the detail supervisory Visits Are Reimbursable three times per Calendar year.Calendar.! Also required for Maxalt When Maxalt or sumatriptan productshave Not Been reimbursed Within days. On your remittance statement Goals Over a 6 Month Period, and/or Positive Rehabilitation.. The Procedure/revenue Code is Not Appropriate for Members gender payment/denial Information is required for Maxalt When or. Ndc codes Code may Not Be Billed for dialysis Services exceeds the maximum daily amount per Provider, per Aid! Reimbursement Rates on file Disease Program for the Date Of Service ( DOS ) ( EOB ) And?! Med Set-up for Members gender Service is Not Necessary ; the Member Has Shown no Significant Progress... Medical Bill it is sent to you after your dentist visit, And outlines costs! Eighth Diagnosis Code Includes IUD Cost Code is Not Necessary ; the Member is Not enrolled for Entire detail Span... Provider WhoReceived Prior Authorization payment Has Already Been Issued for this PA. RA/EOMB. Drug claim Form Utilizing NDC codes your MassHealth Provider manual Included In Reimbursement Allergy...

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