One or more Diagnosis Codes are not applicable to the members gender. The To Date Of Service(DOS) for the First Occurrence Span Code is required. Seventh Occurrence Code Date is required. Procedure not payable for Place of Service. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). Denied due to Claim Contains Future Dates Of Service. Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. Claim Is Being Reprocessed Through The System. Continue ToUse Appropriate Codes On Billing Claim(s). Provider is not eligible for reimbursement for this service. Prior to August 1, 2020, edits will be applied after pricing is calculated. Third Other Surgical Code Date is required. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). The Fax number is (877) 213-7258. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. 105 NO PAYMENT DUE. Disposable medical supplies are payable only once per trip, per member, per provider. Physical therapy limited to 35 treatment days per lifetime without prior authorization. NDC- National Drug Code is restricted by member age. Service Denied. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Additional Reimbursement Is Denied. 4. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Services billed are included in the nursing home rate structure. TPA Certification Required For Reimbursement For This Procedure. This Is A Duplicate Request. Member is assigned to a Hospice provider. 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. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Rebill On Pharmacy Claim Form. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Detail To Date Of Service(DOS) is invalid. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Service Denied. The first position of the attending UPIN must be alphabetic. Denied. Was Unable To Process This Request. One or more Diagnosis Code(s) is invalid in positions 10 through 25. Denied. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. Principal Diagnosis 7 Not Applicable To Members Sex. This claim is a duplicate of a claim currently in process. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. Individual Audiology Procedures Included In Basic Comprehensive Audiometry. Request For Training Reimbursement Denied. Please Verify The Units And Dollars Billed. (National Drug Code). Please Resubmit. This Mutually Exclusive Procedure Code Remains Denied. Claim Denied. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Members File Shows Other Insurance. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. 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 . Progressive Insurance Eob Explanation Codes. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Third Diagnosis Code (dx) (dx) is not on file. Not A WCDP Benefit. How do I get a NAIC number? The Members Poor Motivation, The Long-standing Nature Of The Disability and aLack Of Progress Substantiate Denial. No Substitution Indicator Invalid For Non-innovator Drugs Not On The Current Wisconsin MAC List. Copayment Should Not Be Deducted From Amount Billed. Critical care in non-air ambulance is not covered. Services billed exceed prior authorized amount. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). 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. The Maximum Allowable Was Previously Approved/authorized. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Co. 609 . A Qualified Provider Application Is Being Mailed To You. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. Denied due to Member Not Eligibile For All/partial Dates. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Admit Diagnosis Code is invalid for the Date(s) of Service. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Denied. The Existing Appliance Has Not Been Worn For Three Years. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. CNAs Eligibility For Nat Reimbursement Has Expired. No action required. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. Individual Replacements Reimbursed As Dispensing A Complete Appliance. A Version Of Software (PES) Was In Error. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. This member is eligible for Medication Therapy Management services. Valid Numbers Are Important For DUR Purposes. Please Correct And Resubmit. Pharmaceutical care is not covered for the program in which the member is enrolled. A Fourth Occurrence Code Date is required. The Primary Diagnosis Code is inappropriate for the Procedure Code. Master Level Providers Must Bill Under A Mental Health Clinic Number; Not Under a Private Practice Or Supervisor Number. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. No Matching, Complete Reporting Form Is On File For This Client. Allstate insurance code: 37907. . Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Your Explanation of Benefits (EOB) is a paper or electronic statement provided by your dental insurance company, which breaks down any dental treatments or services that you have received. Medicare Part A Or B Charges Are Missing Or Incorrect. Active Treatment Dose Is Only Approved Once In Six Month Period. The quantity billed of the NDC is not equally divisible by the NDC package size. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. The National Drug Code (NDC) was reimbursed at a generic rate. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Has Already Issued A Payment To Your NF For This Level L Screen. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Billing Provider Type and Specialty is not allowable for the Place of Service. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. Duplicate Item Of A Claim Being Processed. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. The Service Performed Was Not The Same As That Authorized By . The Primary Diagnosis Code is inappropriate for the Revenue Code. Procedure Code is not payable for SeniorCare participants. 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. Personal injury protection insurance is mandatory in some states and optional or not offered at all in other states. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Reconsideration With Documentation Warranting More X-rays. Print. They might also make a digital copy available . Please Correct Claim And Resubmit. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. 2 above. Dispense Date Of Service(DOS) is invalid. The To Date Of Service(DOS) for the Second Occurrence Span Code is required. 2. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. Billed Amount On Detail Paid By WWWP. Claim Reduced Due To Member/participant Spenddown. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. . Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Pricing Adjustment/ Maximum Allowable Fee pricing used. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. No Extractions Performed. A Payment For The CNAs Competency Test Has Already Been Issued. A valid procedure code is required on WWWP institutional claims. Denied as duplicate claim. Approved. Service(s) Denied/cutback. Claim date(s) of service modified to adhere to Policy. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. 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. We Are Recouping The Payment. CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider. Copay - Fixed amount you pay to the provider when This claim/service is pending for program review. The fair market value of property; technically, replacement cost less depreciation.. Actuary. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Correct And Resubmit. (800) 297-6909. Other Medicare Managed Care Response not received within 120 days for providerbased bill. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. DME rental beyond the initial 180 day period is not payable without prior authorization. NJM Insurance Codes. Please Contact The Hospital Prior Resubmitting This Claim. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. Good Faith Claim Denied. This Adjustment/reconsideration Request Was Initiated By . The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. After Progressive adjudicates the bill, AccidentEDI will send an 835 Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. The service is not reimbursable for the members benefit plan. Services Submitted On Improper Claim Form. Contact Wisconsin s Billing And Policy Correspondence Unit. eBill Clearinghouse. Member has Medicare Supplemental coverage for the Date(s) of Service. Do Not Use Informational Code(s) When Submitting Billing Claim(s). Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable. CO 7 Denial Code - The Procedure/revenue code is inconsistent with the patient's gender. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. The Number In The National Provider Identifier (NPI) Section On This Request IsNot A Number Assigned To A Certified Nursing Facility For This Date Of Service(DOS). Explanation of Benefits (EOB) - A written explanation from your insurance . An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. Procedure not allowed for the CLIA Certification Type. Resubmit charges for covered service(s) denied by Medicare on a claim. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Quantity submitted matches original claim. Denied/cutback. Procedure code missing from bill. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. Member has Medicare Managed Care for the Date(s) of Service. Area of the Oral Cavity is required for Procedure Code. EOBs do look a lot like . The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. An Explanation of Benefits from Anthem Blue Cross, retrieved online. Please Contact Your District Nurse To Have This Corrected. Frequency or number of injections exceed program policy guidelines. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Do Not Submit Claims With Zero Or Negative Net Billed. your insurance plan will begin sharing the cost with you (see "co-insurance"). The Surgical Procedure Code is restricted. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Menu. The service requested is not allowable for the Diagnosis indicated. Enter ZIP Code. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. The diagnosis code is not reimbursable for the claim type submitted. Good Faith Claim Has Previously Been Denied By Certifying Agency. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Online EOB Statements 835:CO*22 615 Denied Incidental Procedure 835:CO*B1 A Previously Submitted Adjustment Request Is Currently In Process. Please Furnish A UB92 Revenue Code And Corresponding Description. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. This Claim Has Been Manually Priced Based On Family Deductible. This is a duplicate claim. Result of Service submitted indicates the prescription was not filled. It has now been removed from the provider manuals . This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Claim Denied. 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. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Save on auto when you add property . Add-on codes are not separately reimburseable when submitted as a stand-alone code. Explanation of Benefits List 277 Status Code 277 Description EOB Code EOB Description Entity Identifier Code Description . Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. Unable To Process Your Adjustment Request due to Provider Not Found. Claim: The claim will usually contain the itemized bill, statements, and charges for your visit. This claim must contain at least one specified Surgical Procedure Code. 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. Amount Paid Reduced By Amount Of Other Insurance Payment. RULE 133.240. Request Denied. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. Reimbursement limit for all adjunctive emergency services is exceeded. Physical Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. The Member Is Enrolled In An HMO. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Service code is invalid . Secondary Diagnosis Code (dx) is not on file. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Review Has Determined No Adjustment Payment Allowed. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. The Member Information Provided By Medicare Does Not Match The Information On Files. Reimbursement For This Service Has Been Approved. The Other Payer ID qualifier is invalid for . The total billed amount is missing or is less than the sum of the detail billed amounts. Service(s) Denied. Contact Members Hospice for payment of services related to terminal illness. your coverage was still in effect . Denied due to Provider Is Not Certified To Bill WCDP Claims. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Number On Claim Does Not Match Number On Prior Authorization Request. Keep EOB statements with your health insurance records for reference. Medically Needy Claim Denied. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. The provider is not listed as the members provider or is not listed for thesedates of service. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Denied. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. The Rendering Providers taxonomy code in the header is invalid. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. NULL CO NULL N10 043 Denied. Denied. This Claim Is A Reissue of a Previous Claim. PIP is a coverage in which the auto insurance company pays, within the specified limits, the medical, hospital and funeral expenses of the insured person, people in the insured vehicle and pedestrians struck by the insured vehicle. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). This procedure is limited to once per day. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). 24260 Progressive insurance code: 24260. Admission Date is on or after date of receipt of claim. Rebill Using Correct Procedure Code. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Service is reimbursable only once per calendar month. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Service billed is bundled with another service and cannot be reimbursed separately. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. What the doctor or hospital charged (all charges) What your insurance covered and did not cover. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Please Use This Claim Number For Further Transactions. This service is not payable for the same Date Of Service(DOS) as another service included on the same claim, according to the National Correct Coding Initiative. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Dates Of Service Must Be Itemized. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. Two Informational Modifiers Required When Billing This Procedure Code. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Not all claims generate . The Service Billed Does Not Match The Prior Authorized Service. You can search for insurance companies by name or by their 3-digit code. CPT is registered trademark of American Medical Association. Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. EOBs are created when an insurance provider processes a claim for services received. Indicated Diagnosis Is Not Applicable To Members Sex. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. This Information Is Required For Payment Of Inhibition Of Labor. Member Is Enrolled In A Family Care CMO. Claim Denied. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. NDC- National Drug Code is not covered on a pharmacy claim. The Treatment Request Is Not Consistent With The Members Diagnosis. Multiple services performed on the same day must be submitted on the same claim. What is the 3 digit code for Progressive Insurance? Rendering Provider Type and/or Specialty is not allowable for the service billed. Prescribing Provider UPIN Or Provider Number Missing. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. The Travel component for this service must be billed on the same claim as the associated service. Second Surgical Opinion Guidelines Not Met. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests.
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