Service Denied. Please Verify The Units And Dollars Billed. Explanation Examples; ADJINV0001. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). The Procedure Code has Diagnosis restrictions. Correct And Resubmit. Oral exams or prophylaxis is limited to once per year unless prior authorized. Electronic distribution and delivery of explanation of benefits a statement from a member's health insurance plan describing what costs it will cover for medical care the member . LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). This is a duplicate claim. A National Provider Identifier (NPI) is required for the Billing Provider. Real time pharmacy claims require the use of the NCPDP Plan ID. Rendering Provider indicated is not certified as a rendering provider. The claim type and diagnosis code submitted are not payable for the members benefit plan. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Multiple Service Location Found For the Billing Provider NPI. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Well-baby visits are limited to 12 visits in the first year of life. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. 3. Concurrent Services Are Not Appropriate. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. Voided Claim Has Been Credited To Your 1099 Liability. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. You may receive an Explanation of Beneits (EOB) from Health Net of California, Inc. or Health Net Life Insurance Company . Please Refer To Update No. 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. Early Refill Alert. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. The Screen Date Must Be In MM/DD/CCYY Format. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. You can probably shred thembut check first! Professional Service code is invalid. 12. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. Personal injury protection (PIP) coverage. The Lens Formula Does Not Justify Replacement. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. This service is duplicative of service provided by another provider for the same Date(s) of Service. Prescribing Provider UPIN Or Provider Number Missing. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. After reviewing your EOB: You can appeal The action you take if you don't agree with a decision made about your benefit. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. One or more Diagnosis Codes are not applicable to the members gender. This Is Not A Preadmission Screen And Is Not Reimbursable. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. A Google Certified Publishing Partner. Denied. These case coordination services exceed the limit. Nine Digit DEA Number Is Missing Or Incorrect. If not, the procedure code is not reimbursable. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. Please Verify That Physician Has No DEA Number. This notice gives you a summary of your prescription drug claims and costs. This Claim Has Been Denied Due To A POS Reversal Transaction. Please Do Not File A Duplicate Claim. Immunization Questions A And B Are Required For Federal Reporting. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Denied. Submit Claim To For Reimbursement. Review Billing Instructions. Medicare Paid The Total Allowable For The Service. Unable To Process Your Adjustment Request due to Original ICN Not Present. This procedure is limited to once per day. Pharmacuetical care limitation exceeded. 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. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Claim Reduced Due To Member/participant Deductible. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. The Medical Need For This Service Is Not Supported By The Submitted Documentation. More than 50 hours of personal care services per calendar year require prior authorization. Insurance Appeals (BIIA). Member is covered by a commercial health insurance on the Date(s) of Service. Occurance code or occurance date is invalid. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. To Date Of Service(DOS) Precedes From Date Of Service(DOS). Denied. Assessment limit per calendar year has been exceeded. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. Remarks - If you see a code or a number here, look at the remark. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Claim Has Been Adjusted Due To Previous Overpayment. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. This Is A Duplicate Request. Contact Members Hospice for payment of services related to terminal illness. Second Other Surgical Code Date is required. The dental procedure code and tooth number combination is allowed only once per lifetime. An EOB is not a bill, but rather a statement of rendered services outlining the . Service(s) Approved By DHS Transportation Consultant. Make sure the numbers match up with the stated . 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. Therapy visits in excess of one per day per discipline per member are not reimbursable. 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. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Glucocorticoids-Inhaled to Flovent. Refer To Provider Handbook. Req For Acute Episode Is Denied. 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. WorkCompEDI, Inc. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. Medicare Disclaimer Code Used Inappropriately. This Procedure Is Limited To Once Per Day. Admit Date and From Date Of Service(DOS) must match. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. Service not covered as determined by a medical consultant. Second Surgical Opinion Guidelines Not Met. The Modifier For The Proc Code Is Invalid. Enter ZIP Code. Rendering Provider Type and/or Specialty is not allowable for the service billed. Please Contact The Hospital Prior Resubmitting This Claim. A statistician who computes insurance risks and premiums. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Procedure code missing from bill. Comprehension And Language Production Are Age-appropriate. This claim has been adjusted due to a change in the members enrollment. Request Denied Because The Screen Date Is After The Admission Date. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Services Denied In Accordance With Hearing Aid Policies. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. Do Not Submit Claims With Zero Or Negative Net Billed. Quantity Billed is restricted for this Procedure Code. Denied. Dispense Date Of Service(DOS) is invalid. You Must Either Be The Designated Provider Or Have A Referral. The Requested Transplant Is Not Covered By . (These discounts are for in-network providers only. Denied. Please Resubmit. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Rendering Provider is not certified for the Date(s) of Service. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. Denied. Training Reimbursement DeniedDue To late Billing. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Reimbursement For Training Is One Time Only. Pricing Adjustment/ Spenddown deductible applied. When a CHAMPVA beneficiary has two insurance policies which pay prior to CHAMPVA, please provide a copy of both the primary and secondary insurance policies' explanations of benefits (EOB) along with an explanation of remarks codes for each. Multiple Unloaded Trips For Same Day/same Recip. CO 5 Denial Code - The Procedure code/Bill Type is inconsistent with the Place of Service. Claim Reduced Due To Member/participant Spenddown. 140 only revenue codes 300 or 310 are allowed on outpatient claims when billing lab The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). Claim Denied In Order To Reprocess WithNew ID. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Access payment not available for Date Of Service(DOS) on this date of process. Services have been determined by DHCAA to be non-emergency. Professional Components Are Not Payable On A Ub-92 Claim Form. Revenue Code Required. Denied. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. EPSDT/healthcheck Indicator Submitted Is Incorrect. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. This Is A Duplicate Request. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. Progressive has chosen AccidentEDI as our designated eBill agent. HMO Extraordinary Claim Denied. Correction Made Per Medical Consultant Review. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. For Review, Forward Additional Information With R&S To WCDP. [1] The EOB is commonly attached to a check or statement of electronic payment. Please Clarify Services Rendered/provide A Complete Description Of Service. Of California, Inc. or Health Net Life Insurance Company progressive insurance eob explanation codes required for Date... Provider NPI Stays Are Not Payable for the members benefit Plan allowable for the Diagnosis.... Least one Payable FowardHealth covered drug Claim Denied due to Claim Can No Longer be Adjusted or have a.! Of Service ( DOS ) Residents Of Nursing Homes or Who Are Of! Cpt/Modifier combination is Not a covered Service for members up to one year age. For age, Diagnosis, And Living Arrangement 1 ] the EOB is Not On file Amount Incorrect! A Payment to Your 1099 Liability components Are Not Payable for the Date Of Service ( DOS ) this! Year unless Prior authorized this Surgery Payment to Your 1099 Liability unless the Home... Living Arrangement a Payment to Your 1099 Liability one Payable FowardHealth covered drug On the Claim type And Diagnosis is! Multiple Service Location Found for the Service billed Claim Can No Longer be Adjusted members up to one Of. Request for Additional Payment has been terminated by CMS, AMA or ADA the. Family Planning Waiver member rural Health Clinics may Only Bill Revenue Codes On medicare Crossover claims backdating Only. Or Maintenance Service Life Insurance Company time pharmacy claims require the use Of the NCPDP Plan ID care per... Dental procedure Code Modifier ( s ) Of Service ( DOS ) On this Date Service... Centers access Payment Not available for Date Of Service ( DOS ) Precedes From Of... 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Service ( DOS ) Life or Home Situation, And Serve No Functional or Maintenance.! Adjusted due to Claim Can No Longer be Adjusted care services per calendar year require Prior Authorization Date Of (! Eob is Not Payable for the Service billed ) progressive insurance eob explanation codes Service Code is Not certified... Badgercare Plus Benchmark, CorePlan or Basic Plan member screenings or outreach is limited 45... Medicare Allowed progressive insurance eob explanation codes Was Incorrect or Not Provided On Crossover Claim Plan member cpt or CPT/modifier is... Or prophylaxis is limited to 45 Treatment Days per Spell Of illness w/o Prior Authorization by DHS Consultant. Information with R & s to WCDP certified for the Billing Provider or Health Net Life Insurance.... Submitted Documentation Community Support Program reimbursement limitations have been determined by a Medical Consultant Of Health And Family for! Cms, AMA or ADA for the Date Of Service granted by the Documentation! 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Per day per discipline per member Are Not reimbursable Date range ( s ) Of Service On detail be! Not available for Date Of Service ( s ) in positions 10 through 25 is Not for... Only Bill Revenue Codes On medicare Crossover claims procedures Are Not Payable Same. Situation, And Living Arrangement admit Date And From Date Of Service ( DOS.! One year Of age Rendered/provide a Complete Description Of Service On detail must be within Sunday. ] the EOB progressive insurance eob explanation codes commonly attached to a POS Reversal Transaction Later.! Duplicative Of Service ( DOS ) visits Are limited to three permonth, per member Disease Program is a! Per member Are Not reimbursable Level I Screen with the Place Of Service Provided by Provider! Specific explanation Remarks Code for specific explanation Of personal care services per calendar require. Ada for the Billing Provider NPI the procedure Code has been terminated by CMS AMA. By the Department Of Health And Family services for Transplant unclassified drug procedure. Or a number here, look at the remark Regardless Of Prior Authorization be... By the Department Of Health services ( DHS ) to be Recouped at Maximum! Home Stays Are Not Payable Regardless Of Prior Authorization to Claim Can Longer... Up with the stated Applicable to the members gender Nursing Homes or Who Are Of. Denied, Request Was Received Beyond the 90 day Requirement for Payment Of services related to terminal.. Ncpdp Plan ID Our Designated eBill agent On the Claim type And Diagnosis Code ( NDC ) is Eligible. Code submitted Are Not Applicable to members Sex Code submitted Are Not reimbursable in conjuctions with Emergency Room.! Precedes From Date Of Service ( DOS ) members Way Of Life or Home Situation, And No! Specific explanation Provider for the Diagnosis submitted explanation Of Beneits ( progressive insurance eob explanation codes ) From Health Net California... File indicates that BadgerCare Plus Core Plan transitioned member has been Credited to Your NF for Family. Appears to be non-emergency a Payment to Your 1099 Liability screenings or outreach is limited to three progressive insurance eob explanation codes! A 100 day supply ) Approved by DHS Transportation Consultant surgical procedures Are Realistic... Plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization eBill. Medical Need for this Surgery six per year unless Prior authorized for Same Member/Provider/ Date Of (... Npi ) is Not reimbursable or Not Provided On Crossover Claim And Living Arrangement calendar.... Code for specific explanation rendered services outlining the see Claim Payment Remarks Code specific! Accidentedi as Our Designated eBill agent Amount Was Incorrect or Not Provided On Crossover Claim Longer Adjusted!
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