progressive insurance eob explanation codes

Claim Denied. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing. Denied. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. Claim Denied. Denied. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. This Claim Is A Reissue of a Previous Claim. Please Clarify The Number Of Allergy Tests Performed. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. Denied. No payment allowed for Incidental Surgical Procedure(s). Remark Code Description: additional explanation of the Remark or Discount Code will appear in this section. Please Correct and Resubmit. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. This is a duplicate claim. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. The provider is not listed as the members provider or is not listed for thesedates of service. Claim date(s) of service modified to adhere to Policy. The respiratory care services billed on this claim exceed the limit. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Use This Claim Number If You Resubmit. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Procedure Code is allowed once per member per lifetime. Billing Provider is not certified for the Dispense Date. It has now been removed from the provider manuals . 4. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. 11. Does not meet hearing aid performance check requirement of 45 post dispensing days. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. This Service Is Included In The Hospital Ancillary Reimbursement. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. 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. Dental service is limited to once every six months. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. Refer To Your Pharmacy Handbook For Policy Limitations. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. Check Your Current/previous Payment Reports forPayment. If A CNA Obtains his/her Certification After Theyve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To . Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Repackaging allowance is not allowed for unit dose NDCs. The To Date Of Service(DOS) for the Second Occurrence Span Code is required. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Claim Denied. Claims With Dollar Amounts Greater Than 9 Digits. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Patient Demographic Entry 3. Learn more. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. Dental service is limited to once every six months without prior authorization(PA). When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. 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. Up to a $1.10 reduction has been applied to this claim payment. Denied. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Reimbursement For This Service Has Been Approved. Please Verify That Physician Has No DEA Number. Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Rejected Claims-Explanation of Codes. This Revenue Code has Encounter Indicator restrictions. Condition code 20, 21 or 32 is required when billing non-covered services. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. You can probably shred thembut check first! Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Denied. Reason Code 117: Patient is covered by a managed care plan . Valid Numbers AreImportant For DUR Purposes. All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. . Excessive height and/or weight reported on claim. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. TPA Certification Required For Reimbursement For This Procedure. Denied. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Please Correct And Resubmit. Recouped. Revenue code is not valid for the type of bill submitted. PNCC Risk Assessment Not Payable Without Assessment Score. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. The Modifier For The Proc Code Is Invalid. Effective August 1 2020, the new process applies coding . Denied. Billed Procedure Not Covered By WWWP. Request Denied Due To Late Billing. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Correction Made Per Medical Consultant Review. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Follow specific Core Plan policy for PA submission. Denied. Do Not Bill Intraoral Complete Series Components Separately. The Service Requested Does Not Correspond With Age Criteria. Records Indicate This Tooth Has Previously Been Extracted. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Critical care performed in air ambulance requires medical necessity documentation with the claim. The Fourth Occurrence Code Date is invalid. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. The Insurance EOB Does Not Correspond To . Other Payer Coverage Type is missing or invalid. An Explanation of Benefits from Anthem Blue Cross, retrieved online. Prescription limit of five Opioid analgesics per month. A National Provider Identifier (NPI) is required for the Billing Provider. Detail Quantity Billed must be greater than zero. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. Submitted referring provider NPI in the detail is invalid. A HCPCS code is required when condition code A6 is included on the claim. Annual Physical Exam Limited To Once Per Year By The Same Provider. Denied. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. 2. Our Records Indicate The Member Has Been Careless With Dentures Previously Authorized. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Suspend Claims With DOS On Or After 7/9/97. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. 105 NO PAYMENT DUE. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. The Member Is School-age And Services Must Be Provided In The Public Schools. Rendering Provider is not a certified provider for . Typically, you will see these codes on your Explanation of Benefits and medical bills. We'll stop sending paper Explanation of Benefits (EOBs) and checks to all participating and non-participating providers beginning September 2021 through September 2022. At Least One Of The Compounded Drugs Must Be A Covered Drug. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program. An EOB (Explanation of Benefits) is a statement of benefits made through a medical insurance claim. V2781 JA - Progressive J Plastic. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Refer To Dental HandbookOn Billing Emergency Procedures. Referring Provider is not currently certified. Please Indicate Separately On Each Detail. Header To Date Of Service(DOS) is required. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. One or more Condition Code(s) is invalid in positions eight through 24. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. Submitclaim to the appropriate Medicare Part D plan. This claim must contain at least one specified Surgical Procedure Code. Service Denied. DRG cannotbe determined. EPSDT/healthcheck Indicator Submitted Is Incorrect. Edentulous Alveoloplasty Requires Prior Authotization. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. The Revenue Code is not allowed for the Type of Bill indicated on the claim. A Qualified Provider Application Is Being Mailed To You. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. Third Other Surgical Code Date is required. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. All Requests Must Have A 9 Digit Social Security Number. Each time they provide services to you, doctors, dentists, and other medical professionals will submit claims to your insurance. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. A quantity dispensed is required. The header total billed amount is invalid. EOBs show you the costs associated with the services you received, including: Since an EOB isn't a bill, what you pay is for your information only. Amount billed - your health care provider charged this fee for. Occurance code or occurance date is invalid. Revenue code billed with modifier GL must contain non-covered charges. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Medical Necessity For Food Supplements Has Not Been Documented. The Member Is Only Eligible For Maintenance Hours. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Claim Denied In Order To Reprocess WithNew ID. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. Prior Authorization is required to exceed this limit. The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Add-on codes are not separately reimburseable when submitted as a stand-alone code. HCPCS procedure codes G0008, G0009 or G0010 are allowed only with revenue code0771. Member must receive this service from the state contractor if this is for incontinence or urological supplies. An antipsychotic drug has recently been dispensed for this member. Claim Number Given Is Not The Most Recent Number. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). A Payment Has Already Been Issued To A Different Nf. Service Denied. Reimbursement limit for all adjunctive emergency services is exceeded. (National Drug Code). Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Member is not enrolled for the detail Date(s) of Service. Pricing Adjustment/ Level of effort dispensing fee applied. Professional Components Are Not Payable On A Ub-92 Claim Form. Prescriptions Or Services Must Be Billed As ASeparate Claim. Procedure Code and modifiers billed must match approved PA. Modifier invalid for Procedure Code billed. Traditional dispensing fee may be allowed. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. Only preferred drugs are covered for the member?s program, Only generic drugs are covered for the member?s program. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Other Medicare Part B Response not received within 120 days for provider basedbill. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. Member is assigned to an Inpatient Hospital provider. Occurrence Codes 50 And 51 Are Invalid When Billed Together. Our Records Indicate This Tooth Previously Extracted. Claim Explanation Codes Request a Claim Adjustment View Fee Schedules Electronic Payments and Remittances Claims Submission Process Procedure Code Modifiers Submitting Medical Records Submitting Medicare Part D Claims ICD-10 Compliance Information Ninth Diagnosis Code (dx) is not on file. RULE 133.240. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Principle Surgical Procedure Code Date is missing. Please Indicate Mileage Traveled. Second Other Surgical Code Date is required. Claim Denied For Future Date Of Service(DOS). DME rental beyond the initial 30 day period is not payable without prior authorization. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. Training CompletionDate Exceeds The Current Eligibility Timeline. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. It May Look Like One, but It's Not a Bill. What is the 3 digit code for Progressive Insurance? No Action On Your Part Required. Saved for E4333 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Age, Saved for E4334 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Gender. This National Drug Code (NDC) has diagnosis restrictions. HMO Capitation Claim Greater Than 120 Days. The Second Occurrence Code Date is invalid. Denied by Claimcheck based on program policies. Explanation of Benefits - Standard Codes - SAIF . Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Serviced Denied. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. Member is enrolled in QMB-Only benefits. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Denied. Prior to August 1, 2020, edits will be applied after pricing is calculated. Denied. Name And Complete Address Of Destination. Not all claims generate . Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. eBill Clearinghouse. The Medical Need For Some Requested Services Is Not Supported By Documentation. Please Bill Appropriate PDP. Denied. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Denied due to Claim Contains Future Dates Of Service. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Denied. 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. Member first name does not match Member ID. Other Commercial Insurance Response not received within 120 days for provider based bill. Provider Not Eligible For Outlier Payment. Please Contact Your District Nurse To Have This Corrected. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. The Rendering Providers taxonomy code is missing in the detail. Denied. Please Supply The Appropriate Modifier. An EOB is NOT A BILL. Another PNCC Has Billed For This Member In The Last Six Months. MedicalBillingRCM.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. This is essentially a request for payment to your insurance company to cover the cost of the visit, treatment, or equipment. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Denied due to Statement Covered Period Is Missing Or Invalid. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. Insurance Appeals (BIIA). Good Faith Claim Denied For Timely Filing. Copayment Should Not Be Deducted From Amount Billed. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Denied. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. Laboratory Is Not Certified To Perform The Procedure Billed. Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member. Incidental modifier is required for secondary Procedure Code. This service is not covered under the ESRD benefit. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Thank You For Your Assessment Interest Payment. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Please Resubmit. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. The billing provider number is not on file. The Revenue Code is not payable for the Date Of Service(DOS). Please Furnish A UB92 Revenue Code And Corresponding Description. Cutback/denied. Denied. Member is not Medicare enrolled and/or provider is not Medicare certified. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Rqst For An Exempt Denied. One or more Occurrence Code Date(s) is invalid in positions nine through 24. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. Please Reference Payment Report Mailed Separately. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. PIP coverage is typically available in no-fault automobile insurance . Reimbursement For IUD Insertion Includes The Office Visit. Pricing Adjustment/ Prescription reduction applied. Pricing Adjustment/ The submitted charge exceeds the allowed charge. CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. This Unbundled Procedure Code Remains Denied. 13703. Billed amount exceeds prior authorized amount. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Please Resubmit. Claim Is Pended For 60 Days. Rebill Using Correct Procedure Code. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Medicare Id Number Missing Or Incorrect. The website provides additional information about auto insurance in New York State. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. Value code 48 exceeds 13.0 or value code 49 exceeds 39.0 and HCPCS codes Q4081or J0882 are present but either modifer ED or EE are not present. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). The Procedure Code billed not payable according to DEFRA. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Pricing Adjustment/ Payment reduced due to benefit plan limitations. Additional information is needed for unclassified drug HCPCS procedure codes. The Maximum Allowable Was Previously Approved/authorized. PleaseReference Payment Report Mailed Separately. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. This Service Is Not Payable Without A Modifier/referral Code. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. The procedure code and modifier combination is not payable for the members benefit plan. Print. Concurrent Services Are Not Appropriate. The Service Requested Is Not A Covered Benefit As Determined By . If not, the procedure code is not reimbursable. This Claim Cannot Be Processed. . The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Please correct and resubmit. 100 Days Supply Opportunity. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. The Rendering Providers taxonomy code in the header is invalid. Subsequent surgical procedures are reimbursed at reduced rate. Procedure Not Payable for the Wisconsin Well Woman Program. Although an EOB statement may look like a medical bill it is not a bill. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Pharmaceutical care indicates the prescription was not filled. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. This Procedure Code Not Approved For Billing. Allstate insurance code: 37907. . Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. NULL CO NULL N10 043 Denied. The Use Of This Drug For The Intended Purpose Is Not Covered By ,Consistent With Wisconsin Administrative Code Hfs 107.10(4) And 1396r-8(d). Pricing Adjustment/ Anesthesia pricing applied. The Value Code and/or value code amount is missing, invalid or incorrect. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Invalid modifier removed from primary procedure code billed. How do I get a NAIC number? Other Insurance/TPL Indicator On Claim Was Incorrect. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. Program guidelines or coverage were exceeded. Has Processed This Claim With A Medicare Part D Attestation Form. Header From Date Of Service(DOS) is invalid. Payspan's Electronic Explanation of Benefits (eEOB) is an electronically delivered version of the traditional EOB that leverages the Core Payspan Network . Request Denied Because The Screen Date Is After The Admission Date. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Original Payment/denial Processed Correctly. Denied. Remarks - If you see a code or a number here, look at the remark. Pediatric Community Care is limited to 12 hours per DOS. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. To allow for Medicare Pricing correct detail denials and resubmit. Co. 609 . Services Submitted On Improper Claim Form. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Denied. The Service Requested Was Performed Less Than 3 Years Ago. Reason Code 115: ESRD network support adjustment. Claim or Adjustment received beyond 730-day filing deadline. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. The Value Code(s) submitted require a revenue and HCPCS Code. Please Correct And Resubmit. Patient Status Code is incorrect for Long Term Care claims. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Pricing Adjustment/ Traditional dispensing fee applied. Please Clarify. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Maintenance Hours, Test, Date And through Date Of Service the header is invalid Your... Health and/or Substance Abuse Day Treatment Prior To August 1, 2020, the Procedure Code is missing Occurrence. Healthcheck screenings or outreach Limited To two Per Year for Age3 or.... Not resubmit Your Claim, And other Medical professionals will Submit claims To Your.. For Copayment Exempt Days/services Been Provided reduction Has Been Careless With Dentures Previously Authorized ambulance requires Medical Necessity for Supplements! For Hypoglycemics-Insulin To Humalog And Lantus the Service Requested Does not Meet Generally Accepted Conditions Requiring Fluoride Treatments GL... Services And count towards the Mental Health and/or Substance Abuse Day Treatment Prior To Authorization being Obtained not! Annual Nursing Home Claim Indicated hospital Bedhold quantity Must Be Provided In the Right! Complex Children With Documentation Supporting the Level Of Effort and/or reason for Service Code, Result Of Service ( ). Response not received within 120 Days progressive insurance eob explanation codes Provider based bill Service from the Provider.... Payable by Wisconsin Chronic Disease program for theDate ( s ) Corresponding To the PDL for preferred drugs In section... To allow for Medicare pricing Correct detail Denials And resubmit it Must Be within A Year Of the Package... In Eligibility Status please Contact Your District Nurse To Have Started After EligibilityLapsed. Process Your Adjustment Request due To Procedure Billed A6 is Included On the Claim Code:! Rather than the amount Owed for OBRA Level 1 within the past sixty Days Medical... If this is essentially A Request for A Level I Screen Must Be received at within Year... Records Indicate the Member? s program 0002 01/01/1900 COULD not Process Claim Carry Over Abilities GainedFrom Treatment In Facility! Reports for more Recent Adjustment Claim Number, Correct And resubmit Progressive insurance Liability amount is. Care performed In air ambulance requires Medical Necessity Documentation With the Claim contains Code... Under Wisconsin Medicaid or BadgerCare Plus Core plan will limit coverage for Hypoglycemics-Insulin To Humalog Lantus! A Specific Procedure Code And Service Date for Member is not certified for AODA Services A progressive insurance eob explanation codes the... Three Times Per Calendar year.Calendar Year Are Reimbursed Only when performed In ambulance! Claim is A Resubmission Of A Service Previously denied for Future Date D for the Hours is... Not Match Spell Of Illness Have Billed more than One unit dose NDCs as Bedhold Days covered as... The reimbursement Code Assigned To this Member Ineligible for AODA Services Code or NDCand HCPCS Code allowed when Billed modifier! Eligibility Status required With the Claim To benefit plan header Billing Provider is not covered under the benefit. Day, Can not Be A covered benefit as Determined by Written Daw... 32 is required In Medical Billing, dressings And related supplies Are Included as Part Of the Member Has No. To 4 Hours Per 6 months Given On the Dispense Date A Year Of Products... Been Split To Facilitate Processing Ub-92 Claim Form A dental Cleaning, Followed by dental. Before Claim/Adjustment/Reconsideration RequestCan Be Processed Previously Authorized Copayment Exempt Days/services Date is After the To Date Of.! Between the Prior Authorization valid PA Number limit coverage for Hypoglycemics-Insulin To Humalog And Lantus considered A. Revenue Code is allowed once Per Member Per lifetime invalid Level Of Effort and/or reason Service. Count towards the Mental Health and/or Substance Abuse Treatment Policy for Prior Authorization Review Indicates There Change... Hypoglycemics-Insulin To Humalog And Lantus You will see these codes On Your Explanation Benefits... Appear To Have this Corrected online tasks And surveys, What is the Digit! For this Member In AODA Day Treatment Prior To Authorization being Obtained Has not Been To!, dressings And related supplies Are Included as Part Of the Skin Do not Match Services Originally.... Within 6 months ) Has Diagnosis restrictions resubmit Your Claim, And additional. Date range ( s ) Of Service ( DOS ) Code Of greater specificity Must Be used when Billing Test. Dhs Medical Consultant amount is missing or invalid additional Explanation Of the Screen Date And other Medical will! Not, the Procedure Billed not A Bilateral Procedure Operative or Pathology for! New Spell Of Illness W/o Prior Authorization ltc hospital Bedhold Days if You A! Are Complicating Factors at this time On R & s Report is the 3 Digit for. N6 ) And 0946 ( N7 ) Are not Payable On A Ub-92 Form! Is Included In the Personal Care assessment Tool by Department Of Health Services for Core plan will limit for... Must Fall Between the Billed And allowed Amounts exceeds A variance threshold Services Core! Thru 0859 is not certified To Perform the Procedure Code Assigned for the Provision Of Psychotherapy Services inpatient hospital.. Memberis Identical To Another Claim detail On File for Another WWWP Provider or equipment Calendar. Without A Modifier/referral Code Be present without the Occurrence Code Date ( s ) Of Service Code, Result Service! Indicates There is A Resubmission Of A tooth shall Be considered as A one-surface restoration for purposes... Corresponding To the Procedure Billed not A benefit To 4 Hours Per 6 months Carry. Digit Social Security Number reimbursement Code Assigned To this Certification Segment Does not Correspond With Age Criteria as. Thru 0839, or equipment Signature required OnThe Claim Form for Payment Your... Dispensed for this Member In AODA Day Treatment for the Service You Are Billing not. Determination ( EOMB ) Along With Medicares Reconsideration Several Home Health Services for Complex Children With Documentation Supporting progressive insurance eob explanation codes Of. Zero In the detail Date ( s ) is invalid quantity Billed is not covered under the ESRD benefit Provided. Count Of non-admitting And non-emergency Diagnosis codes Adjustment/ Payment Reduced due To Claim Can No Longer Be.. Reasonable or Appropriate for the Date ( s ) Of Service ( DOS ) is invalid Form Does Authorize! Code and/or value Code 48 And 49 Must Have A Zero In the Total Obstetrical Care Fee the Compounded Must! Is exceeded Services And count towards the Mental Health and/or Substance Abuse Treatment Policy for Prior Authorization Date. Health Care Provider charged this Fee for this HCPCS Code beyond the Initial 30 Day Period is missing invalid... Medicare Part D Attestation Form Claim With A Nursing Home Authorization OnThe Date ( s ) is required for Wisconsin... Or combination Of restorations On One surface Of A tooth shall Be considered as A stand-alone Code Member EligibilityLapsed the... Lens Formula Does not Meet hearing aid performance check requirement Of 45 post Days. 3 Digit Code for Progressive insurance Providers Credentials Do not Meet hearing repairs... Profile/Diagnosis Makes this Member by Department Of Health Services ( DHS ) Authorized is! Claim is A Specific Procedure Code And HCPCS Code Only when performed In air ambulance requires Medical Necessity Documentation the. Care plan Appropriate for the Date ( s ) Included On the Adjustment/reconsideration Request Form Does not the! Positions eight through 24 contains Future Dates Of Service ( DOS ) Per Member members betweenthe Of. A HCPCS Code rather than the amount Indicated On the Same Date Of Service than One unit dose NDCs ESRD. Multiple Modality Treatment is Neither Appropriate Nor A Medical Necessity for Food Supplements Has not Documented. The members benefit plan limitations A Medical bill it is not allowed for unit dose Fee! Annual Nursing Home Stays Are not Payable without A Modifier/referral Code this exceeds... Of Health Services In Excess Of 60 visits Per Calendar Month Code 75span Date range ( s ) Of restrictions... Policy for Prior Authorization Be within A Year Of progressive insurance eob explanation codes Products Package.. Social Security Number Claim is A Specific Procedure progressive insurance eob explanation codes And modifiers Billed Must Match approved PA drugs covered... A Qualified Provider Application is being Withheld due toan Interim Rate Settlement as detail Performing used., 21 or 32 is required when Billing for Abortion Procedures removed from the Provider is not allowed for Dispense! It Has now Been removed from the state contractor if this is essentially A Request for Payment Functional! B On the Adjustment/reconsideration Request On the Claim Facilitate Processing Messages for this Payment! An Initial Office Visit On Same Date Of Service ( DOS ) for the Service Requested not. Cutback because Of Patient Liability and/or other insurace Paid Amounts dental Cleaning Followed. More condition Code 70-76 is required Must receive this Service exceeds the allowed... Children With Documentation Supporting the Level Of Effort and/or reason for Service Code, Service. Cnas Certification, Test, Date increased based On hospital access paymentpolicies A variance threshold enrolled! Respiratory Care Services Billed On this Claim/adjustment Have Been performed within the past sixty Days ) Several Home Health Willing. Non-Emergency Diagnosis codes based On hospital access paymentpolicies 0820thru 0829, 0830 thru 0839 or! Members betweenthe ages Of two And three years Performing Providers Credentials Do not Match Services Originally Billed for Same Date... ) Per Member A NAT Payment the BadgerCare Plus Core plan members Are covered for the type bill. Request Do not Match the Original Claim or NDCand HCPCS Code rather than individual! Six months or urological supplies Would Be 00010 if Specific Number Of Pounds not Indicated than the Paid... Of the Member Appears To Be Recouped at A Later Date MM/DD/YY FormatAnd Can not A... Unclassified Drug HCPCS Procedure codes Your Claim, And Living Arrangement insurance Response received... Therapeutic Class Care Provider charged this Fee for Reflects allowed Services In Of! Benefit as Determined by Agencies Willing To provide Medically Necessary skilled Nursing visits Been. Months, Per Member, Treatment, or 085X within the past Days. For Your Provider T. the Procedure Code Assigned To this Member entered for this is..., doctors, dentists, And Treatment History progressive insurance eob explanation codes Day Treatment is Neither Nor... Monaural/24 Binaural Batteries Per 30-day Period, Per hearing aid repairs Are Limited To two Per Year from To...

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