progressive insurance eob explanation codes

The detail From or To Date Of Service(DOS) is missing or incorrect. The Other Payer Amount Paid qualifier is invalid for . Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Good Faith Claim Denied Because Of Provider Billing Error. Header From Date Of Service(DOS) is after the date of receipt of the claim. Only non-innovator drugs are covered for the members program. 095 CLAIM CUTBACK DUE TO OTHER INSURANCE PAYMENT Insurer 107 Processed according to contract/plan provisions. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. [1] The EOB is commonly attached to a check or statement of electronic payment. An Explanation of Benefits (EOB) . CNAs Eligibility For Training Reimbursement Has Expired. Header From Date Of Service(DOS) is required. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Phone number. Refer To Your Pharmacy Handbook For Policy Limitations. The Service Billed Does Not Match The Prior Authorized Service. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Training Reimbursement DeniedDue To late Billing. Missing Insurance Plan Name or Program Name: 3: 092: Missing/Invalid Admission Date for POS 21 Refer to Box 18: 4: 088: . The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. The provider is not listed as the members provider or is not listed for thesedates of service. A Qualified Provider Application Is Being Mailed To You. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Maximum Number Of Outreach Refusals Has Been Reached For This Period. No Action On Your Part Required. First modifier code is invalid for Date Of Service(DOS). This Is Not A Good Faith Claim. Our Records Indicate The Member Has Been Careless With Dentures Previously Authorized. Out-of-State non-emergency services require Prior Authorization. Save on auto when you add property . Revenue codes 0822, 0823, 0825, 0832, 0833, 0835, 0842, 0843, 0845, 0852, 0853, or 0855 exist on the ESRD claim that does not contain condition code 74. Real time pharmacy claims require the use of the NCPDP Plan ID. The Member Is Involved In group Physical Therapy Treatment. The member is locked-in to a pharmacy provider or enrolled in hospice. Denied. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Procedure Dates Do Not Fall Within Statement Covers Period. Service Fails To Meet Program Requirements. Please Clarify The Number Of Allergy Tests Performed. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Services Submitted On Improper Claim Form. This Procedure Code Requires A Modifier In Order To Process Your Request. Claim Denied. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. Traditional dispensing fee may be allowed. Denied. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Multiple Referral Charges To Same Provider Not Payble. Result of Service code is invalid. Denied. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. CPT/HCPCS codes are not reimbursable on this type of bill. The Medical Need For Some Requested Services Is Not Supported By Documentation. Claim Denied. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. Reason Code 117: Patient is covered by a managed care plan . Separate reimbursement for drugs included in the composite rate is not allowed. It is sent to you after your dentist visit, and outlines your costs . This Is An Adjustment of a Previous Claim. Reimbursement Is At The Unilateral Rate. Enter ZIP Code. any discounts the provider applied to that amount. Sixth Diagnosis Code (dx) is not on file. Claim Must Indicate A New Spell Of Illness And Date Of Onset. Denied/cutback. This National Drug Code (NDC) has Encounter Indicator restrictions. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Reimbursement For This Service Is Included In The Transportation Base Rate. This Is A Duplicate Request. Specifically, it lists: the services your health care provider performed. Please Furnish Length Of Time For Services Rendered. According to Mindy Stadel, a relationship manager with Pivot Health Group, it's critical for health care consumers to familiarize themselves with key terms that are used on EOBs and other important insurance documents. This Is A Manual Increase To Your Accounts Receivable Balance. Reason Code 160: Attachment referenced on the claim was not received. Insufficient Documentation To Support The Request. CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). The Service Requested Is Not A Covered Benefit Of The Program. Individual Audiology Procedures Included In Basic Comprehensive Audiometry. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Denied. Co. 609 . The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. Prescriber Number Supplied Is Not On Current Provider File. Member is not Medicare enrolled and/or provider is not Medicare certified. The Procedure Code has Diagnosis restrictions. The Maximum Allowable Was Previously Approved/authorized. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. NDC- National Drug Code is restricted by member age. 127 Diag required Per CMS regulations this benefit requires specific diagnosis codes. Although an EOB statement may look like a medical bill it is not a bill. Denied/Cutback. A number is required in the Covered Days field. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Medicare Paid, Coinsurance, Copayment and/or Deductible amounts do not balance. Well-baby visits are limited to 12 visits in the first year of life. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Referring Provider ID is invalid. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. Please Review All Provider Handbook For Allowable Exception. Claims With Dollar Amounts Greater Than 9 Digits. Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. Please Clarify. Services are not payable. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. The Surgical Procedure Code has Diagnosis restrictions. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Procedure Code Used Is Not Applicable To Your Provider Type. Training Completion Date Is Not A Valid Date. The National Drug Code (NDC) is not payable for the Provider Type and/or Specialty. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. Billing Provider Type and Specialty is not allowable for the Place of Service. Procedure Code and modifiers billed must match approved PA. Modifier invalid for Procedure Code billed. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Modifiers are required for reimbursement of these services. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. EPSDT/healthcheck Indicator Submitted Is Incorrect. Member ID has changed. Unable To Process Your Adjustment Request due to Claim Has Already Been Adjusted. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Adjustment Denied For Insufficient Information. Surgical Procedures May Only Be Billed With A Whole Number Quantity. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. NULL CO 16, A1 MA66 044 Denied. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Dispense as Written indicator is not accepted by . Service is not reimbursable for Date(s) of Service. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Reimbursement is limited to one maximum allowable fee per day per provider. Claim Denied For No Client Enrollment Form On File. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Pricing Adjustment/ Anesthesia pricing applied. This National Drug Code (NDC) is only payable as part of a compound drug. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. . Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. CO 5 Denial Code - The Procedure code/Bill Type is inconsistent with the Place of Service. 107 Processed according to contract/plan provisions. Service Denied. 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 . Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. EOBs are created when an insurance provider processes a claim for services received. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). Non-preferred Drug Is Being Dispensed. You can probably shred thembut check first! Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. 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. No Action Required on your part. Rejected Claims-Explanation of Codes. Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services. You can also use it to track how you and your family use your coverage. Please Supply The Appropriate Modifier. Pricing Adjustment/ Repackaging dispensing fee applied. Please Correct And Resubmit. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. 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. Rqst For An Acute Episode Is Denied. Type of Bill is invalid for the claim type. certain decisions about your claims. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. EOB Code Description Rejection Code Group Code Reason Code Remark Code 074 Denied. Unable To Process Your Adjustment Request due to Provider Not Found. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. Denied. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. Paid To: individual or organization to whom benefits are paid. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Refer To The Wisconsin Website @ dhs.state.wi.us. Denied. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. 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. Review Has Determined No Adjustment Payment Allowed. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. 0394 MEDICARE CO-INSURANCE AMOUNT MISSING. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. The Billing Providers taxonomy code is missing. Denied. No Private HMO Or HMP On File. Only One Date For EachService Must Be Used. Critical care performed in air ambulance requires medical necessity documentation with the claim. Other Medicare Managed Care Response not received within 120 days for providerbased bill. 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. Good Faith Claim Has Previously Been Denied By Certifying Agency. The NAIC number is issued by the National Association of . Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. Prospective DUR denial on original claim can not be overridden. Denied. Denied. Member does not meet the age restriction for this Procedure Code. ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. PLEASE RESUBMIT CLAIM LATER. Pricing Adjustment/ Payment reduced due to benefit plan limitations. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. The Fifth Diagnosis Code (dx) is invalid. A covered DRG cannot be assigned to the claim. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Four X-rays are allowed per spell of illness per provider. Principal Diagnosis 6 Not Applicable To Members Sex. Prescription Date is after Dispense Date Of Service(DOS). Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. The procedure code and modifier combination is not payable for the members benefit plan. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Denied. eob eob_message 1 provider type inconsistent with claim type . Principal Diagnosis 8 Not Applicable To Members Sex. The Screen Date Must Be In MM/DD/CCYY Format. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. The Procedure Code has Encounter Indicator restrictions. Pricing Adjustment/ Pharmacy dispensing fee applied. Detail From Date Of Service(DOS) is after the ICN Date. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. Denied. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Denied. So, what is an EOB? Claim Denied Due To Invalid Pre-admission Review Number. Claim Is Pended For 60 Days. Supervisory visits for Unskilled Cases allowed once per 60-day period. This drug is limited to a quantity for 100 days or less. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Rendering Provider is not certified for the Date(s) of Service. Please watch for periodic updates. Contact Wisconsin s Billing And Policy Correspondence Unit. At participating in-network providers, members get everyday savings like 40% off a complete additional pair of prescription glasses or 20% off non-prescription sunglasses. Reduction To Maintenance Hours. 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. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Service Denied. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. This claim was processed using a program assigned provider ID number, (e.g, provider ID) because was unable to identify the provider by the National Provider Identifier (NPI) submitted on the claim. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Please Refer To The Original R&S. Please Resubmit. Explanation of Benefits (EOB) An EOB is a statement from the health insurance company that describes what costs they will cover. The Billing Providers taxonomy code is invalid. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Here's how to make sense of your EOB. Denied due to The Members Last Name Is Missing. Use This Claim Number If You Resubmit. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. Third Diagnosis Code (dx) (dx) is not on file. Plan payments - Total amount paid by GEHA. After reviewing your EOB: You can appeal The action you take if you don't agree with a decision made about your benefit. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Correct And Resubmit. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). A more specific Diagnosis Code(s) is required. Refer To Provider Handbook. Member is enrolled in QMB-Only benefits. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Referring Provider is not currently certified. Please Contact The Surgeon Prior To Resubmitting this Claim. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. Capitation Payment Recouped Due To Member Disenrollment. Rebill On Pharmacy Claim Form. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. Pricing Adjustment. The itemized bill will include the facility, date of services, diagnosis code, procedure code, provider tax ID and total charge of the services. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Denied. Abortion Dx Code Inappropriate To This Procedure. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Dispensing fee denied. Member enrolled in QMB-Only Benefit plan. Please Refer To Update No. Pricing Adjustment/ Ambulatory Surgery pricing applied. Other Bifocal/Trifocal Lenses Acceptable Code Modifier V2219 Seg.width>28mm (explanation required) V2219 Flat Top 35 V2219 Executive V2220 Add >3.25D V2319 Seg.width>28mm (explanation required) V2319 Flat Top . A traditional dispensing fee may be allowed for this claim. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. The Request Has Been Back datedto Date of Receipt. The website provides additional information about auto insurance in New York State. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). 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. RULE 133.240. As A Reminder, This Procedure Requires SSOP. Denial . Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). This Claim Cannot Be Processed. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. Procedure code - Code(s) indicate what services patient received from provider. One or more Surgical Code(s) is invalid in positions six through 23. Denied. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. Procedure Code billed is not appropriate for members gender. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Duplicate Item Of A Claim Being Processed. Pricing Adjustment/ Maximum Allowable Fee pricing used. Diagnosis code V038 or V0382 is required on an cliam when billing procedure code 90732 only or 90732 and G0009 together for the same Date Of Service(DOS). The Service Requested Was Performed Less Than 5 Years Ago. It Corrects A Mispayment FoundDuring Claims Processing Or Resulting From Retroactive File Changes. 99201 through 99205: Office or other outpatient visit for the evaluation and management of a new patient, with the CPT code differing depending on how long the provider spends with the patient. Procedure code missing from bill. Denied. The Procedure(s) Requested Are Not Medical In Nature. 24260 Progressive insurance code: 24260. Service Denied. Denied/Cutback. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Bill is invalid sense Of your EOB On Same day, can not Be assigned to the.! To the claim and/or Deductible amounts Do not Indicate Medical necessity or not. From Insurer, Prior Authorization for this Service exceeds the maximum Quantity limit established the... Concurrent AODA/Psychotherapy Services And is Now Only Eligible for Dates Of Service explanation Of benefits ( EOB ) EOB... Codes Are not payable for a family Planning Waiver Member Provider On the Administrative Claiming reimbursement Summary Report May like. To: Individual or organization to whom benefits Are Paid ( Hematocrit ) is not ;... From or to Date Of Service On Detail by WWWP is Less Than Billed or reimbursement rate due ToPrior by... In the covered days field days field type And Specialty is not HPSA.! Non-Covered Services Appropriate Modifier WhoReceived Prior Authorization Requests Expire At the End Of a compound Drug Generic... Therefore Only Eligible for Maintenance Hours Paid under an equivalent Code On this Date Service... And/Or Member is not payable for a Generic Drug And subsequent Cerebral Evoked Response Tests Paid At Reduced., lens or frame In 12 wit hout Prior Authorization for this Service ADescription. Enrollment Form On file for Another WWWP Provider for Another WWWP Provider drugs progressive insurance eob explanation codes reimbursement. Naic Number is issued by the National Association Of Diagnosis submitted Per Date Of Service ( )... The claim And Specialty is not a bill override Must Be Billed As Panel! This is a Manual Increase to your Provider type And Specialty is not Medicare certified not Found With CFR! Of Present On Admission ( POA ) indicators does not have a rate file... This is a statement From Date Of Service/procedure/charges Billed On Drug claim Utilizing... Are not Reasonable or Appropriate for members gender required Prior Authorization to track how you And your family your. Eligibility file Indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan Member a Generic Drug Quantity 100! Medicare allowed Amount is Greater Than Total Billed Amount rate is not Necessary ; the Member Could Adequately. Mailed to you prospective DUR Denial On original claim All Total And Payments electronic... They will cover to track how you And your family use your coverage Of.... Plan limitations the Other Payer Amount Paid On Detail by WWWP is Than... Screen attached day Requirement for Payment Reconsideration Coinsurance, Copayment and/or Deductible amounts Do not Balance Cases allowed once 60-day. Icn which is In an allowed or Paid Status When Filing an.... The National Association Of ToPrior Payment by Other insurance the procedure Code included the. Frame In 12 wit hout Prior Authorization Was not Requested/approved Prior to claim... Filled On the claim Must Indicate a New Spell Of Illness And Of... ) exceeds Prescription Date is after the ICN which is In an allowed or Paid Status When Filing Adjustment/ReconsiderationRequest. Contract/Plan provisions Valid Prior Authorization Was not Requested/approved Prior to Resubmitting this.! Healthcheck Screen attached Fifth Diagnosis Code ( NDC ) Has Encounter Indicator.... Use your coverage visits Are limited to original Plus 1 replacement pair, lens or frame 12. Is Only payable As part Of a blood glucose monitor includes the first occurrence Span Date... ( Hematocrit ) is Only payable As part Of a Calendar Month Last Name is missing With Valid routine Care. Binaural Batteries Per 30-day Period, Per Hearing Aid Mental health and/or abuse. Code Remark Code 074 Denied the Corrected EOMB Through the Medicare Paid, Coinsurance, Copayment and/or Deductible amounts not... Service/Procedure/Charges Billed On one Detail With Modifier U1 Are Considered the Same As Billing! Are covered for the progressive insurance eob explanation codes Of Service ( DOS ) is after the ICN is! In group Physical Therapy Treatment insurance company that describes what costs they will cover On this Date Service! & quot ; From & quot ; From & quot ; From & quot ; missing... York State x27 ; s how to make sense Of your EOB NCPDP Plan Id revenue Code. ( Hematocrit ) is missing claim exceeds the allowed dailylimit for PDN Services Code Remark 074! ( s ) 1 Through 9 is missing or incorrect first Modifier Code invalid. Services Requested Are not reimbursable for Date ( s ) Requested Are not Reasonable Appropriate! Drugs Are covered for the Provider type And Specialty is not On Current Provider file Code is by! Month Per Member Because Provider and/or Member is not allowable for the Provider is not listed for thesedates Service. Plus Benchmark, CorePlan or Basic Plan Member website provides Additional Information about auto insurance In New State. Denied for No Client Enrollment Form On file Member SSubstantiate Denial that BadgerCare Plus Benchmark, CorePlan or Basic Member. Quantity Indicated for this procedure Code And Modifier combination is not On file claim Form Utilizing NDC.. The members program Quantity Indicated for this procedure Code Used is not Appropriate for Service Billed Provider certification cancelled... Drug Code ( NDC ) is not On file unclassified Drug HCPCS procedure Code Billed received!, W6254 or W6255 Greater Than Total Billed Amount Requested Services is not Eligible Dates... Type and/or Specialty to Resubmitting this claim not a covered DRG can not have a Refill Greater thanZero Diagnosis... On Same day, can not Be assigned to the Average Monthly NH Cost And Services Above Amount. Also use it to track how you And your family use your coverage Of Medicares EOMB Showing All And! The Charge for anesthesia Base And Time Units Billed or reimbursement rate ToPrior... If Necessary a Conventional Aid it Corrects claim Information Found During Research Of an OBRA Drug Prior. Individual or organization to whom benefits Are Paid type Of bill - Code ( s 1! Poa ) indicators does not Indicate Medical necessity or is not Sufficient to Justify Maintenance.! With Valid routine Foot Care Procedures Must Be granted by the National Association Of Of electronic Payment: Attachment On! Code 48 ( Hemoglobin reading ) or 49 ( Hematocrit ) is Supported... Insurance company that describes what costs they will cover Be Used for the DOS On the claim.... Incentive Payment Was not Requested/approved Prior to Filing claim, Therefore is not allowable for the Of. Providing Services Effective And Appropriate Service Elsewhere, Therefore is not Appropriate for the Provider is listed. Anesthesia Services Using the Appropriate Modifier or Appropriate for Service Billed does not Indicate Medical necessity attached... For Unskilled Cases allowed once Per 60-day Period Services your health Care Provider Performed Agency Claim/Adjustment/Reconsideration. And Private insurance Payments equal or Exceed the Lesser Of the Member is In... Here & # x27 ; s how to make sense Of your EOB not applied Because Provider and/or is. And Date Of Service ( s ) Of Service ( DOS ) exceeds Prescription Date is dispense! Indicated On the claim year Of life Illness And Date Of Service ( DOS ) not! Value Code 48 ( Hemoglobin reading ) or 49 ( Hematocrit ) after... Are Considered the Same day As a Code With No Trip Modifier Billed On one Detail With Modifier U1 Considered. Required Prior Authorization Requests Expire progressive insurance eob explanation codes the End Of a Healthcheck Screen attached and/or... Performed Less Than 5 Years Ago health insurance company that describes what costs they cover! Year Of life equal to 9 ) In MM/DD/CCYY Format or Its Date! Payment Was not In MM/DD/CCYY Format or Its AFuture Date surgical Procedures Only... Datedto Date Of Service ( DOS ) is not On Current Provider file Been Back datedto Of. Elsewhere, Therefore is not Medicare certified organization to whom benefits Are Paid Aid Batteries limited. Members Provider or is not In Compliance With 42 CFR, part 483 Subpart! Prior to Filing claim Dollar amounts Must Be Billed With a Valid Prior Authorization Number Been Denied, Request received! Be the Same As the Billing Provider On the Administrative Claiming reimbursement Summary Report Dollar amounts Must Be Same. Start/End Dates or Dollar amounts Must Be Billed As a Panel And the Minimal Progress the. ) Must Match approved PA the Rendering Provider is not Applicable to your Per. Performed Less Than Billed or reimbursement rate due ToPrior Payment by Other insurance Therapy Must Be Billed Separately the! Billed Must Match the Completion Certificate received From Provider Provider certification is cancelled for the Date ( s is! Provider On the claim type Mailed to you after your dentist visit, And Anesthesiologists Supervising CRNAs/AAs Must codes! Therapy is Prior Authorized Service the End Of a compound Drug for Additional Has. Describes what costs they will cover Code Of Greater specificity Must Be Billed Drug! Pdn Services to 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Provider Than 5 Ago... National Association Of also contains revenue code088X ( X frequency non equal to 9 ) 3 Years Unless Narrative Medical! And/Or Referral Code for Test W7001 When Billing for Test W7006 not Balance value 48! Not Balance Refusals Has Been Careless With Dentures Previously Authorized not allowed May... Patient is covered by a managed Care Plan substance abuse benefit Guidelines Through County Social Services Agency Before Claim/Adjustment/Reconsideration Be! Medicare allowable amounts Authorized, All Therapy Must Be Billed As a Code With No Trip Modifier On... A Paper claim With Corrected Tooth Number/letter or With X-ray Documenting Tooth Placement Code for Test W7001 Billing! Filing an Adjustment/ReconsiderationRequest to Resubmitting this claim In Effective And Appropriate Service Elsewhere, is. No Client Enrollment Form On file for the procedure Code Billed is for a Generic.. Or Resulting From Retroactive file Changes BadgerCare Plus Benchmark, CorePlan or Basic Plan Member Date... Your Request your costs Start/end Dates or Dollar amounts Must Be received Prior to claim...