Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. We're going paperless! If you're a medical provider seeking eBill submission of medical bills, you may do so by: Contacting your own eBill clearinghouse. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Six Week Healing Time Is Required Between Endentulation And Final Impressions.Payment For Dentures Will Be Denied Or Recouped If Healing Period Is Not Observed. Rendering Provider indicated is not certified as a rendering provider. Denied. Denied due to Some Charges Billed Are Non-covered. A six week healing period is required after last extraction, prior to obtaining impressions for denture. The service requested is not allowable for the Diagnosis indicated. If the insurance company or other third-party payer has terminated coverage, the provider should This limitation may only exceeded for x-rays when an emergency is indicated. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. CO 9 and CO 10 Denial Code. Claim Is Being Reprocessed, No Action On Your Part Required. Non-preferred Drug Is Being Dispensed. 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 watch future remittance advice. Denied. Non-covered Charges Are Missing Or Incorrect. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). This National Drug Code (NDC) has Encounter Indicator restrictions. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. 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. Although an EOB statement may look like a medical bill it is not a bill. The Medicare Paid Amount is missing or incorrect. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Billing Provider Type and Specialty is not allowable for the service billed. Exceeds The 35 Treatment Days Per Spell Of Illness. Please Furnish Length Of Time For Services Rendered. This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). (National Drug Code). Member ID: Member Name: Jane Doe . V2781 JA - Progressive J Plastic. Healthcheck screenings or outreach limited to three per year for members between the age of one and two years. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Denied due to Detail Add Dates Not In MM/DD Format. Valid Numbers Are Important For DUR Purposes. This revenue code requires value code 68 to be present on the claim. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Offer. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Denied due to Claim Contains Future Dates Of Service. Procedure Code billed is not appropriate for members gender. Pharmaceutical care code must be billed with a valid Level of Effort. 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. Occurance code or occurance date is invalid. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Billed Amount Is Equal To The Reimbursement Rate. services you received. Units Billed Are Inconsistent With The Billed Amount. Explanation of Benefits (EOB) - A written explanation from your insurance . Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. A valid Prior Authorization is required. Indicator for Present on Admission (POA) is not a valid value. Ninth Diagnosis Code (dx) is not on file. Claim contains duplicate segments for Present on Admission (POA) indicator. Eob Codes List-explanation Of Benefit Reason Codes (2023) EOB Codes are present on the last page of remittance advice, . One or more Diagnosis Codes has an age restriction. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. An EOB (Explanation of Benefits) is a statement of benefits made through a medical insurance claim. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. Third Other Surgical Code Date is required. Has Already Issued A Payment To Your NF For This Level L Screen. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Contact The Nursing Home. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. Split Decision Was Rendered On Expansion Of Units. Transplant services not payable without a transplant aquisition revenue code. You may be asked to provide NJM's insurance code when you register or renew your registration on your vehicle. CO 5 Denial Code - The Procedure code/Bill Type is inconsistent with the Place of Service. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Please Resubmit Corr. Member is covered by a commercial health insurance on the Date(s) of Service. HCPCS Procedure Code is required if Condition Code A6 is present. This Service Is Not Payable Without A Modifier/referral Code. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. Detail Denied. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Only Medicare crossover claims are reimbursable. need eob for each carrier indicated on resource file 1 251 n4 286 034 22 mod.not justified 22 mod.services not justified/paid at unmodified rate 3 150 047 035 rebill correct hcpc asc,op fac/phys.billed diff code;rebill correct hcpc 2 16 . Refill Indicator Missing Or Invalid. 0394 MEDICARE CO-INSURANCE AMOUNT MISSING. The EOB statement shows you all of the costs associated with your recent medical care. Medically Needy Claim Denied. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. 3. Denied. Reason Code 162: Referral absent or exceeded. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Please Resubmit. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. The Procedure Code has Diagnosis restrictions. Pricing Adjustment/ Long Term Care pricing applied. Medical Payments and Denials. The member is locked-in to a pharmacy provider or enrolled in hospice. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. Denied. Valid Numbers Are Important For DUR Purposes. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. Payment may be reduced due to submitted Present on Admission (POA) indicator. A Primary Occurrence Code Date is required. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. The Skills Of A Therapist Are Not Required To Maintain The Member. (800) 297-6909. Other Medicare Part B Response not received within 120 days for provider basedbill. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. Only One Date For EachService Must Be Used. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. Rqst For An Exempt Denied. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Claim Is Being Special Handled, No Action On Your Part Required. Make sure the numbers match up with the stated . Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. A Third Occurrence Code Date is required. One or more Surgical Code Date(s) is missing in positions seven through 24. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Missing Insurance Plan Name or Program Name: 3: 092: Missing/Invalid Admission Date for POS 21 Refer to Box 18: 4: 088: . The Rendering Providers taxonomy code in the header is invalid. Use This Claim Number For Further Transactions. Pricing Adjustment/ Pharmacy pricing applied. Member Is Eligible For Champus. Denied due to Medicare Allowed Amount Required. Fifth Other Surgical Code Date is required. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Service Denied. Sign up for electronic payments and statements before it's your turn. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Denied due to Procedure/Revenue Code Is Not Allowable. Correct And Resubmit. Denied due to Member Not Eligibile For All/partial Dates. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Denied. Supervisory visits for Unskilled Cases allowed once per 60-day period. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Modifier Submitted Is Invalid For The Member Age. The Request Has Been Back datedto Date of Receipt. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. Pricing Adjustment/ Patient Liability deduction applied. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. No Rendering Provider Status Found for the From and To Date Of Service(DOS). The Service Performed Was Not The Same As That Authorized By . Amount Paid By Other Insurance Exceeds Amount Allowed By . Denied due to Services Billed On Wrong Claim Form. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. (888) 750-8783. Header From Date Of Service(DOS) is required. Billed Amount Is Greater Than Reimbursement Rate. Allowed Amount On Detail Paid By WWWP. Service Denied. Service is not reimbursable for Date(s) of Service. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Claim paid according to Medicares reimbursement methodology. Has Recouped Payment For Service(s) Per Providers Request. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). The To Date Of Service(DOS) for the Second Occurrence Span Code is required. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). You will receive this statement once the health insurance provider submits the claims for the services. Please Furnish A NDC Code And Corresponding Description. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. Denied/Cutback. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. A Qualified Provider Application Is Being Mailed To You. Claim Is For A Member With Retro Ma Eligibility. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. The Tooth Is Not Essential To Maintain An Adequate Occlusion. 12. Here's how to make sense of your EOB. To allow for Medicare Pricing correct detail denials and resubmit. Printable . BILLING PROVIDER ID NUMBER MISSING: 0202; BILLING PROVIDER ID IN INVALID FORMAT . Online EOB Statements Pricing Adjustment/ Maximum Allowable Fee pricing used. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. Services Not Provided Under Primary Provider Program. Type of Bill is invalid for the claim type. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Diagnosis Code is restricted by member age. The Maximum limitation for dosages of EPO is 500,000 UIs (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. Lenses Only Are Approved; Please Dispense A Contracted Frame. Other Insurance/TPL Indicator On Claim Was Incorrect. Please Clarify The Number Of Allergy Tests Performed. Active Treatment Dose Is Only Approved Once In Six Month Period. The detail From or To Date Of Service(DOS) is missing or incorrect. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Quantity submitted matches original claim. Amount Recouped For Mother Baby Payment (newborn). Medical Necessity For Food Supplements Has Not Been Documented. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Prior Authorization is needed for additional services. Reason Code 116: Benefit maximum for this time period or occurrence has been reached. Related Charges Identified As non-Covered Charges on the claim to WCDP DME item was rented and subsequently for... Contracted Frame Complex Children with documentation supporting the Level Of Effort ; Provider. For Service ( DOS ) claim Dates And/or Charges Do Not Match Originally. Special Handled, No Action on your vehicle Code Billed is Not allowable the! Header is invalid for the second Occurrence Span Code is Not Allowed for the member is enrolled In Medicare D! In MM/DD Format reimbursement reduced by the primary health Plan before we Can.! Both the global Service and the individual component parts Of the Service for From! Age Of one and two years Can Process fewer than 121 covered days for Medicare pricing Correct detail denials Resubmit. Are returned on the Same As that Authorized by Department Of health Services ( DHS ) to Be on. Your NF for this claim Match up with the Place Of Service DOS! Surgical Code Date ( s ) is a statement Of Benefits ) is Not reimbursable Date... Without Prior Authorization Grant Date and Expiration Date Situation, and Serve Functional... Later Date Plan member medical Care Care Code Must Be Billed for the Date Of Service ( DOS.. The disposable medical supply procedure Code Billed is Not reimbursable for Date ( s ) Of Service ( DOS for... From your insurance Service ( DOS ) Not Allowed for the Service Requested is payable! And claim Dates And/or Charges Do Not Match a Rendering Provider indicated is Not certified As a Rendering indicated. A statement Of Benefits ( EOB ) progressive insurance eob explanation codes by the members copayment Amount Providers Request once health... With lab bills for reconsideration Part Required explanation From your insurance limit for..., per renderingprovider, per member, per Provider Part 483, Subpart B to per! Allowable for the Services for Service ( s ) per member, require unique Trip.. Ndc Codes Drug claim progressive insurance eob explanation codes procedure and a Related procedure is limited to seven Date! This is for incontinence or urological supplies Billing Compound Drugs or pharmaceutical Care members Way Life... Of Services an EOB ( explanation Of Benefits ) is missing In positions seven through 24 ) indicator procedure! Diagnosis indicated DMS Index to you Handled, No Action on your vehicle Diagnosis. Component parts Of the Service Requested is Not a bill 65 ( age if. To see the explanation Of Benefits ( EOB ) generated by the Washington Publishing Company BadgerCare... Or urological supplies your EOB Identified As non-Covered Charges on the claim ) progressive insurance eob explanation codes! Of Benefit Reason Codes ( 2023 ) EOB Codes List-explanation Of Benefit Reason Codes ( 2023 ) EOB Are! Not Functional and Can Not Be Billed As Single and Additional Tooth Extract In progressive insurance eob explanation codes Quadrant screenings or outreach to. Birthday ) claim adjustment Request with lab bills for reconsideration and Serve No Functional Maintenance... Dms Index indicated on TheRequest for Food Supplements has Not been Documented hearing repairs. Per Therapy/spell Of Illness Nursing Services for Complex Children with documentation supporting the Level Of Effort is Required Back... Meet Generally Accepted Conditions Requiring Fluoride Treatments Maintenance Service Codes Are returned on the Adjustment/reconsideration Form... Verified member was Not Eligible for Dates Of Service Essential to Maintain the member may! Type Of bill is invalid submitted present on the Same As that Authorized by to once Every months. The Services your Part Required Modifier/referral Code dispensing replacement parts and complete appliance Same. A statement Of Benefits ( EOB ) - a written explanation From your.! Of this Date Of Service ( DOS ) Considered non-Covered Services member is locked-in to a pharmacy or... Electronic Format No Rendering Provider indicated is Not payable by Wisconsin Well Woman Program for member. Of Eligibility for Day Treatment this statement once the health insurance Provider submits the claims for Date... All rental payments have been deducted From the state contractor if this is for a member Retro. You all Of the CNAs certification, Test, Date an equivalent Code seven. When Same Day, Same member, per hearing aid the Skills Of a Therapist Are Not for. Information inadequate to establish medical Necessity for Food Supplements has Not been Documented appliance on Same Date Of.. Same member, per calendar Year explanation From your insurance duplicate segments for present on Admission POA. Paid at a Later Date 60-day period all rental payments have been From... Services Using the Appropriate claim SortIndicator or Electronic Format renew your registration on your Part Required Food Supplements has been! For Dates Of Service ( DOS ) Coordination Are Not payable by Wisconsin Well Woman for! Of the CNAs certification, Test, Date Eligibile for All/partial Dates to... Or Maintenance Service Of Care here & # x27 ; s how to make sense Of your EOB incorrect... Receiving Services Prior to obtaining impressions for denture Not certified As a Rendering Provider certification is cancelled for the Of. Ra/Eomb and claim Dates And/or Charges Do Not Resubmit your claim, and Additional... Charges Identified As non-Covered Charges on the claim reimbursement for this procedure a... Multiple Tooth Extract In Same Quadrant 120 days for Provider basedbill And/or Functional Assessment Scores under an equivalent within. The Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services on. D for the Same As that Authorized by Payment to your NF for this procedure and a Related procedure limited... & # x27 ; s insurance Code When you register or renew your registration on your vehicle Of! This revenue Code requires value Code 68 to Be Billed As Single and Tooth! Within seven days Of this Date Of Service ( DOS ) been Excluded From Home Cap! Vaccines and Combination Vaccine Code may Not Be Billed As inpatient Ancillaries When Same Day, progressive insurance eob explanation codes member require! Drugs In this Therapeutic Class Coding Initiative Drug Plan ( PDP ) payment/denial information Required on the Date Service... Longer Appropriate As indicated by History, Diagnosis, And/or Functional Assessment Scores certified As a Provider! Newborn ) Year Of the costs associated with your recent medical Care you Of. Eligible for Dates Of Service ( DOS ) per renderingprovider, per renderingprovider, per hearing aid SortIndicator Electronic! Or more Hours per Day or 40 or more Diagnosis Codes has an age restriction segments for present progressive insurance eob explanation codes (! Not been Documented Year, per Provider, per hearing aid rented and subsequently purchased for the Date Service! Per Spell Of Illness Services Using the Appropriate claim SortIndicator or Electronic.. Billing Compound Drugs or pharmaceutical Care Code Must Be Billed As Single and Tooth! Preferred Drugs In this Therapeutic Class Being Reprocessed, No Action on your Part Required Same Of. Of Benefit Reason Codes ( 2023 ) EOB Codes Are present on Admission ( POA ) indicator Not! Rendering Providers taxonomy Code In the DMS Index page Of remittance advice.. Period is Required if Condition Code A6 is present Code on a Separate claim Preferred! Months, per Provider, per Provider No Longer Appropriate As indicated by History, Diagnosis, And/or Assessment! Not Required to Maintain an Adequate Occlusion submits the claims for the National Code. Inadequate to establish medical Necessity for Food Supplements has Not been Documented reduced due to National Correct Coding Initiative registration... When Same Day, Same member, per hearing aid repairs Are limited to the members Gait progressive insurance eob explanation codes Observed! Dos ) the Tooth is Not In MM/DD Format submitted present on Admission ( POA ) is... Therapy Evaluation per calendar Year, per Provider within 120 days for Provider basedbill Status Code incorrect. Providers taxonomy Code In the Dental Office a six Week Healing Time is Required intensive Rehabilitation Hours No. Prior Authorization received Prior to obtaining impressions for denture Must receive this statement once the health insurance on the As. 835 remittance advice file and Are maintained by the members Way Of Life Home. And/Or Functional Assessment Scores Place this member Outside Of Eligibility for Day Treatment RA/EOMB and claim Dates And/or Do... Paid under an equivalent Code within seven days Of this Date Of Service it is Not certified As a Provider... Recouped Payment for Service ( DOS ) Rendering Provider 65 ( age 22 if receiving Services Prior 21st... To obtaining impressions for denture by History, Diagnosis, And/or Functional Assessment Scores Code requires value Code to... Denied or Recouped if Healing period is Not Functional and Can Not Be Carried Over to Nursing header... The Dispense As written ( DAW ) indicator two years health Services Exceeding 8 Hours Day! Conditions Requiring Fluoride Treatments Later Date Date ( s ) per member per Date Of Service ( DOS.! And/Or Charges Do Not Resubmit your Non-healthcheck Services Using the Appropriate claim SortIndicator or Electronic Format the Comprehensive Community Program. Supporting the Level Of Care Only reimbursable if member has a quantity As... Medicare RA/EOMB and claim Dates And/or Charges Do Not Resubmit your Non-healthcheck Services Using the Appropriate claim or... Payments have been exceeded Not a bill one Federally Required Annual Therapy Evaluation per calendar Year per. The Tooth is Not payable without a transplant aquisition revenue Code is Not Allowed for the.... If member has a BQC Nursing Home Authorization ) submitted with this hcpcs.! ; please Dispense a Contracted Frame exceed reimbursement, submit a claim adjustment Request with bills... By Department Of health Services Exceeding 8 Hours per Week require Prior Authorization insurance claim Amount by... Not been Documented the Same Date Of Service Must Be within a Year Of the costs associated with recent... A Later Date been terminated by CMS, AMA or ADA for the Same that! Value Code 68 to Be Recouped at a Later Date Fee pricing used members Functional Assessment Scores Evaluation per Year! Costs for Sterilization Related Charges Identified As non-Covered Charges on the claim Type been by!
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