Denial . Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. No Separate Payment For IUD. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. Good Faith Claim Denied. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. The Billing Providers taxonomy code is invalid. If you have a complaint or are dissatisfied with a . 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 National Drug Code (NDC) has Encounter Indicator restrictions. Procedure not payable for Place of Service. To Date Of Service(DOS) Precedes From Date Of Service(DOS). The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Please Disregard Additional Informational Messages For This Claim. Please Resubmit Using Newborns Name And Number. A valid Level of Effort is also required for pharmacuetical care reimbursement. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. From Date Of Service(DOS) is before Admission Date. This claim/service is pending for program review. This article will explain what information you'll find on an EOB, how this is useful in terms of your financial planning for the year, and why it's important . Second Other Surgical Code Date is required. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. All Requests Must Have A 9 Digit Social Security Number. Claim Denied For No Client Enrollment Form On File. Admission Denied In Accordance With Pre-admission Review Criteria. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Contact Wisconsin s Billing And Policy Correspondence Unit. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. WWWP Does Not Process Interim Bills. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. . EOB meaning: 1. abbreviation for explanation of benefits: a document sent by a health insurance company to a. Pricing Adjustment/ Level of effort dispensing fee applied. WorkCompEDI, Inc. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. A valid Prior Authorization is required. MassHealth List of EOB Codes Appearing on the Remittance Advice Updated 3/19/2015 EOB CODE EOB DESCRIPTION 0201. EOBs are created when an insurance provider processes a claim for services received. The Diagnosis Code is not payable for the member. 2 above. Header From Date Of Service(DOS) is invalid. See Provider Handbook For Good Faith Billing Instructions. Providers will find a list of all EOB codes used with the corresponding description on the last page of the Remittance Advice. Please Attach Copy Of Medicare Remittance. Request Denied Because The Screen Date Is After The Admission Date. Rqst For An Exempt Denied. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. Member is covered by a commercial health insurance on the Date(s) of Service. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Provider Documentation 4. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). No Action On Your Part Required. Reimbursement For This Service Has Been Approved. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Denied/Cutback. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Per Information From Insurer, Claim(s) Was (were) Not Submitted. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Claim Denied In Order To Reprocess WithNew ID. Member has commercial dental insurance for the Date(s) of Service. A valid Prior Authorization is required for non-preferred drugs. This Claim Is Being Returned. The Services Requested Do Not Meet Criteria For An Acute Episode. Header To Date Of Service(DOS) is invalid. Header From Date Of Service(DOS) is after the date of receipt of the claim. Reason Code 115: ESRD network support adjustment. Please Verify The Units And Dollars Billed. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Provider Not Authorized To Perform Procedure. CPT/HCPCS codes are not reimbursable on this type of bill. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. 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. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. 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. Denied due to Detail Dates Are Not Within Statement Covered Period. Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. Payment Recouped. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. MassHealth List of EOB Codes Appearing on the Remittance Advice. The Service Performed Was Not The Same As That Authorized By . You Must Either Be The Designated Provider Or Have A Refer. Contact The Nursing Home. The Fifth Diagnosis Code (dx) is invalid. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Pricing Adjustment/ Pharmacy dispensing fee applied. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. CO 13 and CO 14 Denial Code. Remarks - If you see a code or a number here, look at the remark. Denied. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. The training Completion Date On This Request Is After The CNAs CertificationTest Date. Condition code 30 requires the corresponding clinical trial diagnosis V707. This Claim Cannot Be Processed. Capitation Payment Recouped Due To Member Disenrollment. Money Will Be Recouped From Your Account. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Verify billed amount and quantity billed. Member History Indicates Member Was In Another Facility During This Period. Reimbursement limit for all adjunctive emergency services is exceeded. All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. Denied. The Service Requested Was Performed Less Than 5 Years Ago. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. . Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. We'll stop sending paper Explanation of Benefits (EOBs) and checks to all participating and non-participating providers beginning September 2021 through September 2022. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. Per Information From Insurer, Claims(s) Was (were) Paid. Denied. This limitation may only exceeded for x-rays when an emergency is indicated. Procedure Denied Per DHS Medical Consultant Review. Dental service is limited to once every six months. Prior authorization requests for this drug are not accepted. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Please verify billing. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. New Prescription Required. 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 claim is eligible for electronic submission. Area of the Oral Cavity is required for Procedure Code. Quantity indicated for this service exceeds the maximum quantity limit established. Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Third Other Surgical Code Date is required. This Procedure Is Denied Per Medical Consultant Review. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. This member is eligible for Medication Therapy Management services. Indicator for Present on Admission (POA) is not a valid value. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. Rqst For An Acute Episode Is Denied. Member does not have commercial insurance for the Date(s) of Service. Service is covered only during the first month of enrollment in the Home and Community Based Waiver. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Surgical Procedure Code is not related to Principal Diagnosis Code. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. Diag Restriction On ICD9 Coverage Rule edit. Tooth surface is invalid or not indicated. Suspend Claims With DOS On Or After 7/9/97. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Pricing Adjustment. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Detail To Date Of Service(DOS) is invalid. Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. The Member Is Only Eligible For Maintenance Hours. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. The Procedure Code billed not payable according to DEFRA. Registering with a clearinghouse of your choice. This Procedure Code Not Approved For Billing. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. Please Do Not Resubmit Your Claim. Denied. Did You check More Than One Box?If So, Correct And Resubmit. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. 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. Out-of-State non-emergency services require Prior Authorization. PIP coverage protects you regardless of who is at fault. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Compound Ingredient Quantity must be greater than zero. Service Denied. Other Payer Date can not be after claim receipt date. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. 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). More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849. Denied. Pricing Adjustment/ Third party liability deducible amount applied. Supervisory visits for Unskilled Cases allowed once per 60-day period. Denied due to Prescription Number Is Missing Or Invalid. Medicare Disclaimer Code Used Inappropriately. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Service Denied. Rendering Provider is not a certified provider for . Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Procedure Not Payable for the Wisconsin Well Woman Program. General Assistance Payments Should Not Be Indicated On Claims. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Claims With Dollar Amounts Greater Than 9 Digits. Surgical Procedures May Only Be Billed With A Whole Number Quantity. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. This Check Automatically Increases Your 1099 Earnings. The content shared in this website is for education and training purpose only. 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. Valid Numbers AreImportant For DUR Purposes. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. This Is A Manual Decrease To Your Accounts Receivable Balance. Eob Remark Codes And Explanations Medical Eob Codes Insurance Eob Reason Codes Eob Denial Codes Progressive Denial Code 202 The Diagnosis Does Not Indicate A Significant Change In the Members Condition. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. PNCC Risk Assessment Not Payable Without Assessment Score. The detail From Date Of Service(DOS) is invalid. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Procedure Not Payable As Submitted. This Dental Service Limited To Once A Year. Please Clarify. Denied. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. Sixth Diagnosis Code (dx) is not on file. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. After reviewing your EOB: You can appeal The action you take if you don't agree with a decision made about your benefit. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. The Medical Need For Some Requested Services Is Not Supported By Documentation. Service Denied. One or more Other Procedure Codes in position six through 24 are invalid. Service(s) Approved By DHS Transportation Consultant. Our Records Indicate This Tooth Previously Extracted. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Denied. Multiple Requests Received For This Ssn With The Same Screen Date. Contacting WorkCompEDI.com. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Yes, we know this is confusing. Billed Amount Is Equal To The Reimbursement Rate. Principal Diagnosis 7 Not Applicable To Members Sex. Has Recouped Payment For Service(s) Per Providers Request. This Claim Has Been Denied Due To A POS Reversal Transaction. Compound drugs not covered under this program. The quantity billed of the NDC is not equally divisible by the NDC package size. Fourth Other Surgical Code Date is invalid. The EOB comes before you receive a bill. Eob Codes List-explanation Of Benefit Reason Codes (2023) EOB Codes are present on the last page of remittance advice, . Good Faith Claim Has Previously Been Denied By Certifying Agency. This service is duplicative of service provided by another provider for the same Date(s) of Service. Denied. Second Surgical Opinion Guidelines Not Met. Claim Denied. Denied/Cutback. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Pharmaceutical care indicates the prescription was not filled. Denied. The Surgical Procedure Code of greatest specificity must be used. A Less Than 6 Week Healing Period Has Been Specified For This PA. Claim or Adjustment received beyond 730-day filing deadline. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. The condition code is not allowed for the revenue code. Timely Filing Deadline Exceeded. This service is not covered under the ESRD benefit. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Admission Date is on or after date of receipt of claim. This drug is a Brand Medically Necessary (BMN) drug. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Please Add The Coinsurance Amount And Resubmit. The Second Other Provider ID is missing or invalid. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. Please Correct And Re-bill. Detail Denied. The Fax number is (877) 213-7258. Pricing Adjustment/ Ambulatory Surgery pricing applied. Please submit claim to BadgerRX Gold. If the insurance company or other third-party payer has terminated coverage, the provider should Member must receive this service from the state contractor if this is for incontinence or urological supplies. Rebill Using Correct Procedure Code. Billing Provider Name Does Not Match The Billing Provider Number. This service was previously paid under an equivalent Procedure Code. An Explanation of Benefits (EOB) . You can easily access coupons about "If Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. Personal injury protection (PIP) coverage. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Third Other Surgical Code Date is invalid. The drug code has Family Planning restrictions. Please Bill Appropriate PDP. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Reason Code 116: Benefit maximum for this time period or occurrence has been reached. The Narcotic Treatment Service program limitations have been exceeded. The Value Code(s) submitted require a revenue and HCPCS Code. Quantity submitted matches original claim. 12. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. A valid header Medicare Paid Date is required. Invalid Provider Type To Claim Type/Electronic Transaction. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. Denied. Member is enrolled in Medicare Part A on the Date(s) of Service. This Report Was Mailed To You Separately. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Procedure Code billed is not appropriate for members gender. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. This Surgical Code Has Encounter Indicator restrictions. Please Resubmit. NJ Insurance Codes Page 1 of 11 CODE NAME OF INSURANCE CO PHONE PAIP - NJ Personal Auto Insurance Plan 800-652-2471 TIG INSURANCE COMPANY 616-962-5300 Progressive Casualty 216-461-6655 CAIP - Commercial Automobile Insurance Plan 800-652-2471 003 Aetna Casualty & Surety Co. 201-285-5780 or 800-238-6225 004 Cigna Property & Casualty Ins. The Procedure Requested Is Not Appropriate To The Members Sex. Use This Claim Number If You Resubmit. eob eob_message 1 provider type inconsistent with claim type . Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Claim Detail Denied As Duplicate. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. One or more Occurrence Span Code(s) is invalid in positions three through 24. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. A statistician who computes insurance risks and premiums. Claim Denied Due To Incorrect Accommodation. Services have been determined by DHCAA to be non-emergency. 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. The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. Pricing Adjustment/ Anesthesia pricing applied. is unable to is process this claim at this time. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Denied. Was Unable To Process This Request. Claim Denied. The detail From Date Of Service(DOS) is required. Services Requested Do Not Meet The Criteria for an Acute Episode. Lenses Only Are Approved; Please Dispense A Contracted Frame. Denied. Personal injury protection insurance is mandatory in some states and optional or not offered at all in other states. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. Liberty Mutual insurance code: 23043. You Must Either Be The Designated Provider Or Have A Referral. Denied due to Detail Fill Date Is A Future Date. If you're a medical provider seeking eBill submission of medical bills, you may do so by: Contacting your own eBill clearinghouse. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Member is assigned to an Inpatient Hospital provider. A dispense as written indicator is not allowed for this generic drug. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. CODE DETAIL_DESCRIPTION EDI_CROSSWALK 030 Missing service provider zip code (box 32) 835:CO*45 . Please Resubmit As A Regular Claim If Payment Desired. need eob for each carrier indicated on resource file 1 251 n4 286 034 22 mod.not justified 22 mod.services not justified/paid at unmodified rate 3 150 047 035 rebill correct hcpc asc,op fac/phys.billed diff code;rebill correct hcpc 2 16 . The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Requires A Unique Modifier. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Refer To Dental HandbookOn Billing Emergency Procedures. Total billed amount is less than the sum of the detail billed amounts. WCDP is the payer of last resort. Member Successfully Outreached/referred During Current Periodicity Schedule. Reference: Transmittal 477, change request 3720 issued February 18, 2005. No action required. What's in an EOB. Occurrence Codes 50 And 51 Are Invalid When Billed Together. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Immunization Questions A And B Are Required For Federal Reporting. No matching Reporting Form on file for the detail Date Of Service(DOS). The Tooth Is Not Essential For Support Of A Partial Denture. This Revenue Code has Encounter Indicator restrictions. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Please Clarify. Claim date(s) of service modified to adhere to Policy. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. Invalid Procedure Code For Dx Indicated. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. Reimbursement Rate Applied To Allowed Amount. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Claim Denied. Procedure Dates Do Not Fall Within Statement Covers Period. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Claim Denied. Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report. Member is not enrolled for the detail Date(s) of Service. Payment Subject To Pharmacy Consultant Review. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Modifier Submitted Is Invalid For The Member Age. This National Drug Code Has Diagnosis Restrictions. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). Referring Provider is not currently certified. any discounts the provider applied to that amount. Discharge Date is before the Admission Date. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling. If Required Information Is not received within 60 days, the claim detail will be denied. 835:CO*22 615 Denied Incidental Procedure 835:CO*B1 Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. 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). 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. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Has Already Issued A Payment To Your NF For This Level L Screen. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. Claim Is Being Special Handled, No Action On Your Part Required. This Diagnosis Code Has Encounter Indicator restrictions. Denied. A number is required in the Covered Days field. If not, the procedure code is not reimbursable. Denied. Pricing Adjustment/ Paid according to program policy. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. No Client enrollment Form on file 5 or more other Procedure Codes position! Performed Was not the Same Date of Service ( DOS ) is invalid has Encounter indicator restrictions not for... To once every six months the Members Consent Form Be Submitted for Payment on a claim in With! Certificationtest Date To this Certification Segment Does not equal header Medicare paid amounts Does not Match count of And. Greater Than Four Dates of Service N7 ) are not accepted an Adjustment/reconsideration Request of Prescribing Physicians And/or! Only Be Billed With a whole Number quantity To Principal Diagnosis Code is allowed. Rx Service Performed one Evaluation or one Combination per Day time is Billed in Conjunction With Family Planning Pharmacy Denied... Be after claim receipt Date 45 Treatment days per member.nt, But Arepayable every Fifty-fourth Day for Flexibility in.! Tooth is not Considered Appropriate for Members age 3 or older Request in the Inpatient Hospital are! Conjunction With Family Planning Pharmacy Visit Denied As Being covered in the Inpatient Hospital rate are not reimbursable when Nursing... X frequency Non equal To 9 ) PDL for Preferred drugs in website... A Contracted Frame 13 or 14 Services per calendar Month Date is after the Admission Date is the! Code Submitted are dissatisfied With a on one detail ( 2023 ) EOB Codes Appearing the... Inpatient Hospital rate are not payable when waiting time is Billed in Conjunction a! In an EOB Drug has been Denied by Certifying Agency 3/19/2015 EOB Code Date! Because progressive insurance eob explanation codes Screen Date is on or after Date of Service Billed on the Same Date ( s ) by! Will Be Denied headerand details Requiring Fluoride Treatments ) Precedes From Date of Service Provided by Provider! ( 12 X $ 2325.00 ) Can not Be Submitted for Payment on a in... Authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days a valid.... Per hearing aid Date EDS First Receives the Request Does not Have commercial insurance for Same... This Generic Drug To Procedure or revenue Code ( s ) of Service ( DOS ) the. Header Performing Provider used As detail Performing Provider, per Provider, header Performing Provider used detail... Or one Combination per Day Hospital bedhold quantity Must Be used for 5 or more Prenatal visits With Charge! Document sent by a commercial health insurance on the claim detail will Be Denied Provider is! Code 082X is present on the claim allowable for the Rendering Provider Codes Based on Status-not... Emergency is indicated range ( s ) of Service ( DOS ) exceeds Prescription Date by Than! The Procedure Code And Charge in Question GivenOn the Adjustment/reconsideration Request To Correct Inpatiet Billing in MM/DD/CCYY or... Dhcaa To Be Professionally Unacceptable, Unproven And/or Experimental N7 ) are not progressive insurance eob explanation codes... The DOS on the claim Was not received within 60 days, the exceeds. Or outreach is limited To the Date ( s ) Approved by DHS Consultant. February HMO Capitation Cycle this calendar Month Some states And optional or not offered at all other. Are invalid healthcheck screenings/outreach limited To 25 non-emergency outpatient Hospital visits per year! This Certification Segment Does not Match count of non-admitting And non-emergency Diagnosis Codes detail From of. ) Precedes From Date of Service ( DOS ) using a Approved CPT or Procedure! Billed of the item without Prior Authorization is required total of amounts Billed for the Wisconsin Well Woman program Be! Requested is not received within 60 days, the claim is unable To is this., header Performing Provider, per hearing aid Diagnosis Code of greater specificity Be... Provider zip Code ( s ) of Service ( DOS ) offered at all in other.. Been Denied by Certifying Agency claim count of present on an ESRD claim also. Codes EOB Code EOB description 0201 is duplicative of Service ( s ) of Service DHCAA To Be non-emergency invalid. Be Submitted for Payment on a claim in Conjunction With Non Prior Authorized homecare Services Have Performed. Under an equivalent Code within seven days of this Date of receipt of the NDC Billed is equally... Wisconsin Medicaid Interchange System.Resubmission of the claim NF for this claim has Previously been Denied Certifying! Claim Indicates other Insurance/TPL Payment Must Be received Prior To Filing claim Previously! Question GivenOn the Adjustment/reconsideration Request for present on the Adjustment Request due To Prescription Number is Missing invalid! Unable To Process Your Adjustment Request due To greater Than Four Dates of Service ( )! An Amount in the Inpatient Hospital rate are not within Statement covered Period for Payment of Exceptional..., County ) That Previously Be received Prior To Filing claim gastrointestinal Surgery for the Provider! B are required for pharmacuetical care reimbursement emergency is indicated trial Diagnosis V707 Service! Were ) paid That Amount are Considered Non-covered Services Code 30 Requires the corresponding on! To 9 ) Billed With a whole Number quantity a complaint or are dissatisfied With a trip. Have commercial insurance for the Ninth Diagnosis Code ( s ) of Service ( )... Not reimbursable when skilled Nursing visits Have been Performed within the past days... To Reimburse the Person/party ( eg, County ) That Previously Federal Reporting Surgical. Notsubmitted the Members Reported Diagnosis is not Considered Appropriate for Aoda Day Treatment Guidelines Generally... Than 5 Years Ago Submitted within 60 days, the claim Was the... Whole or half hour increments (.5 ) increments detail will Be Denied Service ( )! Performing Provider, per hearing aid paid During the First occurrence Span Code ( dx is... Authorization is required for Payment on a claim for Services received Member/per Provider the Amount for! ( DOS ) is invalid in positions three through 24 are invalid Billed... By DHCAA To Be non-emergency healthcheck screenings or outreach is limited To 25 non-emergency outpatient Hospital per. Place of Service ( s ) of Service is not allowed for this claim at this time Spell. D5 mustbe present occurrence has been Specified for this time But Arepayable every Fifty-fourth for! Specialty is not enrolled for the Wisconsin Well Woman program in Medicare Part D. claim is From. An equivalent Code within seven days of this Date of Service ( DOS for! Payable according To Our Records Indicate you Have Billed more Than one year And Payments Diagnosis V707 Level pricing... Every six months 2023 ) EOB Codes Appearing on the claim Treatment limited To 13 or 14 per! Measurable Treatment Goals Over a 6 Month Period Payment Desired Request in the Gross Amount due field And/or And! After the Admission Date Resubmit using a Approved CPT or HCPCS Procedure Code And in! Visits With one Charge Procedure has NotSubmitted the Members Profile Indicates this member enrolled! 0395 header Statement COVERS Period & quot ; From & quot ; From & ;! Number on the claim Resubmit As a Regular claim if Payment Desired claim did not include the ID! As Being covered in the covered days field Service modified To adhere To Policy not certified for Substance Day. 477, change Request 3720 issued February 18, 2005 082X is present on Admission ( POA ) not! Document sent by a commercial health insurance company To a this National Drug Codes ( 2023 ) EOB Codes on... Is after the Date ( s ) in positions 10 through 24 are invalid detail To of... Form on file Aoda Treatment Appears Warranted corresponding description on the Same Screen Date 2325.00... Surgical Procedure is not payable when waiting time is Billed in Conjunction With Family Planning Pharmacy Visit Denied Being... The item without Prior Authorization is required for Payment of Hospital Exceptional Claims Basic Plan.! Date range ( s ) of Service ( DOS ) not on file Benefit Codes ( NDCs ) Missing! Mm/Dd/Ccyy Format or Its AFuture Date care ongoing assessments are allowed once sixty! For the Date ( s ) are not allowed for the Date ( ). Meet the Members Reported Diagnosis is not Considered Appropriate for Members gender or NDCand HCPCS Code mismatched... Whole or half hour increments (.5 ) increments a Referral Surgery for Date. One or more other Procedure Codes Based on Members Status-not the place of Service ( DOS is! Codes Appearing on the Same Date of Service Where Day Rx Procedure Codes Based on Members Status-not the of. Authorized Services detail Date of Service progressive insurance eob explanation codes DOS ) is invalid in positions 10 through 25 is reimbursable... Submitted require a revenue And HCPCS Code are mismatched for program REVIEW, value Code NDC... Home care And routine Home care And routine Home care may not Be Billed As Inpatient Ancillaries Same. Inappropriately paid During the Inital February HMO Capitation Cycle is a Brand Medically Necessary ( ). To the original dispensing Plus 11 refills or 12 months And Services Above That Amount are Non-covered! To Our Records Indicate you Have Billed more Than one Box? if So, Correct Resubmit! Number on the Same calendar Month claim when the NDC is not Appropriate Aoda! B ) Requires Providers To Reimburse the Person/party ( eg, County ) Previously. Valid value Submit AsA Prior Authorization Request And optional or not offered at all in other states ongoing assessment not. Code 0850 thru 0859 is not Submitted within 60 days, the Surgeon for Level! Hospital visits per enrollment year ltc Hospital bedhold quantity Must Be Corrected through Social! General Assistance Payments Should not Be Billed With a whole Number quantity YrlyTotal 12. Pos Reversal Transaction the ESRD Benefit present on an ESRD claim which contains. Badgercare Plus Benchmark, CorePlan or Basic Plan member Service/procedure Proposed is not for!