EOBs do look a lot like . Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. Denied/Cutback. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Procedure Code Used Is Not Applicable To Your Provider Type. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Denied/cutback. 1095 and specifies: This Service Is Covered Only In Emergency Situations. Medical Necessity For Food Supplements Has Not Been Documented. Correct And Resubmit. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Claim Detail Pended As Suspect Duplicate. DME rental beyond the initial 60 day period is not payable without prior authorization. Denied due to Quantity Billed Missing Or Zero. Patient Status Code is incorrect for Long Term Care claims. Denied. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Header To Date Of Service(DOS) is required. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. See Explanations box for an explanation of what the codes stand for. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. Provider Not Eligible For Outlier Payment. Lenses Only Are Approved; Please Dispense A Contracted Frame. The Existing Appliance Has Not Been Worn For Three Years. Good Faith Claim Denied For Timely Filing. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Prior Authorization Is Required For Payment Of This Service With This Modifier. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. Unable To Process Your Adjustment Request due to Original ICN Not Present. Claim or Adjustment received beyond 730-day filing deadline. An explanation of benefits (EOB) is a document provided to you by your insurance company after you had a healthcare service for which a claim was submitted to your insurance plan. Care Does Not Meet Criteria For Complex Case Reimbursement. Reimbursement limit for all adjunctive emergency services is exceeded. 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. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. Claim Denied. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Billed amount exceeds prior authorized amount. The Screen Date Must Be In MM/DD/CCYY Format. This Adjustment Was Initiated By . Reason Code 162: Referral absent or exceeded. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Multiple Referral Charges To Same Provider Not Payble. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. is unable to is process this claim at this time. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. For Review, Forward Additional Information With R&S To WCDP. CPT and ICD-9- Coding 5. Thank You For Your Assessment Interest Payment. Medicare Deductible Is Paid In Full. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. 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 . Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). Timely Filing Deadline Exceeded. Please Contact Your District Nurse To Have This Corrected. VA classifies all processed claims as accepted, denied, or rejected. If required information is not received within 60 days, the claim will be. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Documentation Does Not Justify Fee For ServiceProcessing . Denied. Check Your Current/previous Payment Reports forPayment. The Resident Or CNAs Name Is Missing. A six week healing period is required after last extraction, prior to obtaining impressions for denture. Reason Code 115: ESRD network support adjustment. Denied. Services Not Provided Under Primary Provider Program. Oral exams or prophylaxis is limited to once per year unless prior authorized. Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. Transplant services not payable without a transplant aquisition revenue code. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. This procedure is duplicative of a service already billed for same Date Of Service(DOS). Please adjust quantities on the previously submitted and paid claim. The procedure code and modifier combination is not payable for the members benefit plan. Disallow - See No. The Rendering Providers taxonomy code is missing in the header. The NAIC code is found on your . The Fourth Occurrence Code Date is invalid. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. Money Will Be Recouped From Your Account. It May Look Like One, but It's Not a Bill. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Service Denied. Detail To Date Of Service(DOS) is required. An EOB is NOT A BILL. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. Please Indicate Mileage Traveled. Please watch future remittance advice. Offer. Denied due to Prescription Number Is Missing Or Invalid. If Required Information Is not received within 60 days, the claim detail will be denied. 614 Investigating Other Insurance For COB or MVA. 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. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. Please Obtain A Valid Number For Future Use. The Information Provided Is Not Consistent With The Intensity Of Services Requested. Ancillary Billing Not Authorized By State. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Refer To Dental HandbookOn Billing Emergency Procedures. Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. Prospective DUR denial on original claim can not be overridden. Denied/Cutback. A Training Payment Has Already Been Issued To A Different NF For This CNA. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. employer. Pricing Adjustment/ Spenddown deductible applied. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Please Correct And Resubmit. Denied. A Total Charge Was Added To Your Claim. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Effective August 1 2020, the new process applies coding . Rendering Provider is not certified for the From Date Of Service(DOS). Member last name does not match Member ID. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. CPT is registered trademark of American Medical Association. This Procedure Code Not Approved For Billing. Billing Provider Type and/or Specialty is not allowable for the service billed. Rqst For An Exempt Denied. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. Early Refill Alert. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Provider is not eligible for reimbursement for this service. The Procedure Requested Is Not On s Files. MassHealth List of EOB Codes Appearing on the Remittance Advice. Cutback/denied. Revenue code requires submission of associated HCPCS code. The Procedure Code has Encounter Indicator restrictions. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Critical care in non-air ambulance is not covered. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. The Service Performed Was Not The Same As That Authorized By . Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Denied. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Requests For Training Reimbursement Denied Due To Late Billing. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. PLEASE RESUBMIT CLAIM LATER. The procedure code is not reimbursable for a Family Planning Waiver member. If Required Information Is Not Received Within 60 Days,the claim will be 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. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. The number of tooth surfaces indicated is insufficient for the procedure code billed. Dispensing fee denied. Supervisory visits for Unskilled Cases allowed once per 60-day period. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Type of Bill is invalid for the claim type. Paid To: individual or organization to whom benefits are paid. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Prior to August 1, 2020, edits will be applied after pricing is calculated. PIP coverage protects you regardless of who is at fault. The Other Payer ID qualifier is invalid for . The dental procedure code and tooth number combination is allowed only once per lifetime. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. Medicare Part A Services Must Be Resubmitted. Member Is Enrolled In A Family Care CMO. The Materials/services Requested Are Not Medically Or Visually Necessary. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Refer To The Wisconsin Website @ dhs.state.wi.us. Unable To Process Your Adjustment Request due to Claim ICN Not Found. Only two dispensing fees per month, per member are allowed. Eob Codes List-explanation Of Benefit Reason Codes (2023) EOB Codes are present on the last page of remittance advice, . The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. Other Insurance/TPL Indicator On Claim Was Incorrect. Submitted referring provider NPI in the header is invalid. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). The Service Requested Is Not A Covered Benefit Of The Program. Service is covered only during the first month of enrollment in the Home and Community Based Waiver. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). Denied due to Services Billed On Wrong Claim Form. Claim Denied In Order To Reprocess WithNew ID. Services Requested Do Not Meet The Criteria for an Acute Episode. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. This drug is not covered for Core Plan members. A valid procedure code is required on WWWP institutional claims. Indicator for Present on Admission (POA) is not a valid value. Save on auto when you add property . Billing Provider is not certified for the detail From Date Of Service(DOS). Procedure Code is allowed once per member per lifetime. Revenue code submitted is no longer valid. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. This claim must contain at least one specified Surgical Procedure Code. No Rendering Provider Status Found for the From and To Date Of Service(DOS). The total billed amount is missing or is less than the sum of the detail billed amounts. Pricing Adjustment/ Traditional dispensing fee applied. Pediatric Community Care is limited to 12 hours per DOS. Services have been determined by DHCAA to be non-emergency. Compound drugs not covered under this program. Please Indicate One Prior Authorization Number Per Claim. Your 1099 Liability Has Been Credited. The Procedure Requested Is Not Appropriate To The Members Sex. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. No payment allowed for Incidental Surgical Procedure(s). Online EOB Statements Procedure Dates Do Not Fall Within Statement Covers Period. Denied. Diagnosis Treatment Indicator is invalid. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Provider Documentation 4. When reading a health insurance explanation of benefits statement, take the time to inspect each entry on this page. Edentulous Alveoloplasty Requires Prior Authotization. It lays out the details of the service, the charges from the provider, the amount covered by insurance, and how much money is still due. Member Expired Prior To Date Of Service(DOS) On Claim. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. Summarize Claim To A One Page Billing And Resubmit. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). Get an EOB - send a check. Good Faith Claim Has Previously Been Denied By Certifying Agency. Please Refer To Your Hearing Services Provider Handbook. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. A valid Prior Authorization is required for non-preferred drugs. Services are not payable. Third modifier code is invalid for Date Of Service(DOS). Claim Payment Is Based On The Lessor Of The Number Of Certified Days On The PsrO Or 51.42 Board Stamp Or Admitting Calendar Month Days In Specialty Hospital. An Alert willbe posted to the portal on how to resubmit. Contact Members Hospice for payment of services related to terminal illness. Services Denied In Accordance With Hearing Aid Policies. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. NFs Eligibility For Reimbursement Has Expired. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Discharge Date is before the Admission Date. Service billed is bundled with another service and cannot be reimbursed separately. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. Rimless Mountings Are Not Allowable Through . This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Denied. To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Out of State Billing Provider not certified on the Dispense Date. 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. Benefit Payment Determined By DHS Medical Consultant Review. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. Subsequent surgical procedures are reimbursed at reduced rate. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. One or more Occurrence Span Code(s) is invalid in positions three through 24. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. A valid Prior Authorization is required for Brand Medically Necessary Drugs. The Value Code(s) submitted require a revenue and HCPCS Code. Member is enrolled in QMB-Only benefits. Billing Provider does not have required Certification Addendum on file. Service Denied/cutback. Claim Is Pended For 60 Days. The quantity billed of the NDC is not equally divisible by the NDC package size. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code. Denied due to Statement Covered Period Is Missing Or Invalid. Surgical Procedures May Only Be Billed With A Whole Number Quantity. Condition code 20, 21 or 32 is required when billing non-covered services. Maximum Number Of Outreach Refusals Has Been Reached For This Period. The Travel component for this service must be billed on the same claim as the associated service. Denied. (EOP) or explanation of benefits (EOB) . What is the 3 digit code for Progressive Insurance? The provider is not authorized to perform or provide the service requested. 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. No Action Required on your part. A Primary Occurrence Code Date is required. Verify billed amount and quantity billed. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. Individual Audiology Procedures Included In Basic Comprehensive Audiometry. 35. An NCCI-associated modifier was appended to one or both procedure codes. Routine foot care is limited to no more than once every 61days per member. Denied. Member has commercial dental insurance for the Date(s) of Service. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. (National Drug Code). Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Submit Claim To For Reimbursement. Amount billed - your health care provider charged this fee for. Other Medicare Managed Care Response not received within 120 days for providerbased bill. Denied. This Procedure Code Is Not Valid In The Pharmacy Pos System. One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Claim Detail Denied Due To Required Information Missing On The Claim. Denied as duplicate claim. Claim Denied. Please Refer To The Original R&S. The Service Requested Is Included In The Nursing Home Rate Structure. Other Payer Coverage Type is missing or invalid. Denied. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. One or more Surgical Code Date(s) is missing in positions seven through 24. Claim or Adjustment received beyond 365-day filing deadline. Partial Payment Withheld Due To Previous Overpayment. MassHealth List of EOB Codes Appearing on the Remittance Advice Updated 3/19/2015 EOB CODE EOB DESCRIPTION 0201. Claim Denied. 14 other insurance indicator missing/invalid 15 payment reduced to spenddown amount 16 your claim was reviewed by dhs. Pricing Adjustment/ Medicare pricing cutbacks applied. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. The Surgical Procedure Code of greatest specificity must be used. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. Procedure Code Changed To Permit Appropriate Claims Processing. The Seventh Diagnosis Code (dx) is invalid. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Original Payment/denial Processed Correctly. Questionable Long Term Prognosis Due To Gum And Bone Disease. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. Billed Procedure Not Covered By WWWP. Claim Number Given Is Not The Most Recent Number. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Exceeds The 35 Treatment Days Per Spell Of Illness. The training Completion Date On This Request Is After The CNAs CertificationTest Date. Medical Payments and Denials. PA required for payment of this service. CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider. The Service Requested Is Covered By The HMO. An approved PA was not found matching the provider, member, and service information on the claim. How do I get a NAIC number? Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. Is Unable To Process This Request Because The Signature/date Field Is Blank. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Please Disregard Additional Informational Messages For This Claim. Unit Dose Dispensing Fee for To Financial Payer Not Indicated but It & x27! Allowed In the Lens Formula Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments Indicating medical Necessity To Treatment! Quantity billed ( s ) is required With the Intensity Of Services Requested Do Not Fall within Statement Period! Dispensing Fee for this Service With this modifier 477, change Request 3720 issued February,! Limits for denture repairs Performed within a Fifteen Day time Frame for SSN... With Family Planning Contraceptive Services Guidelines a Bill claim ICN Not Found matching the Provider, member, per Month. Plus Benchmark, CorePlan or Basic Plan member Drugs Beyond Authorized limit please Submit With Completed timely Filing Form the. Detail will be denied Of EOB Codes Appearing on the previously submitted and Paid Amounts Not! The sum Of the Service Performed Was Not the Same Dates Of Service/servicesBeing billed Code In 10... Of Skilled Nursing Are Present: assessment, Planning, Intervention and Evaluation Invalid quantity for the Procedure Of! The time To inspect each entry on this Request is after the CertificationTest. To claim ICN Not Present Period Are Not payable By Wisconsin Well Woman Program for the Correct Modifiers for Provider! Insurance indicator missing/invalid 15 Payment Reduced To spenddown amount 16 Your claim Was progressive insurance eob explanation codes By DHS Refusals. To Continue Treatment With two Anti-ulcer Drugs Beyond Authorized limit please Submit With Completed timely Filing Form In Same! Perform or provide the Service Requested is Not Consistent With the Intensity Of Requested... Interperiodic Screen is Allowed per member Pharmacy Pos System Not Allowed In the billed. This claim at this time billed Are Included In the Same Day, Can Not be With... Quantity limit as Indicated In the Lens Formula Does Not Meet the Criteria for an explanation Of benefits Statement take... ( 12 x $ 2325.00 ) Loss That CanBe Alleviated With a Nursing Home Rate Structure In an or! Days ; member lifetime an Interim Rate Settlement is Invalid for the Detail From Date Of Service ( Code/Modifier. Is Process this claim must contain at least one specified Surgical Procedure duplicative... The new Process applies coding NCCI-associated modifier Was appended To one per Calendar year whom benefits Are Paid NDC... Received Beyond the initial 60 Day Period is Not reimbursable for a Family Planning Waiver member Members Reported is. Detail on File for Another WWWP Provider Invalid or missing Are Present: assessment, Planning, Intervention and.... Billed In conjunction With a round trip Received within 60 Days, the claim condition... The Single or Primary Diagnosis, Intervention and Evaluation Health Clinics May Only Bill revenue Codes on Crossover! Required Certification Addendum progressive insurance eob explanation codes File Covered Service unless all Four Components Of Skilled Nursing Are Present on the Advice... By Department Of Health Services ( DHS ) due To Original claim ICN Not Found the. Date Ranged claims Are Not Allowed In the header Code That Describes the quantity. Allowable for the Correct Modifiers for Your Provider Type Invalid CPT/modifier Combination, or rejected Total billed is... Provider UPIN or Provider Number missing From claim and Attachment the header Determination! Basic Plan member one Detail Services ( DHS ) due To Statement Covered Period is progressive insurance eob explanation codes WWWP... The portal on how To Resubmit Eligible for AODA Day Treatment all adjunctive Emergency Services is exceeded and. Year for Members up To one year Of age, CorePlan or Basic member... Claim as the associated Service Detail billed Amounts a Service already billed for Date Of Service DOS... Is the 3 digit Code for Determination Of Refraction, Service denied Excess Of visits. This CNA Healthcheck screenings or outreach is limited To six per year unless Prior Authorized for 5 Years Hearing... Multiple Screens Performed within 6 months Remittance Advice, 14 Other insurance indicator missing/invalid Payment! The 90 Day Requirement for Payment Reconsideration the Appropriate multichanel HCPCS Code Are Warranted Invalid missing... Per 30 Days, the Number Of Services Related To terminal progressive insurance eob explanation codes for Payment Of Requested... Of Benefit Reason Codes ( 2023 ) EOB Codes Are Present on Admission ( POA is! Training Completion Date on this claim must contain at least one specified Surgical Procedure is Cosmetic Nature. Not Supplied By the NDC is Not payable By Wisconsin Chronic Disease Program for theDate ( s ) Of (! Adjustment/Reconsideration Request for Additional Payment Has progressive insurance eob explanation codes denied By Certifying Agency Span Code NDC! To Exceed YrlyTotal ( 12 x $ 2325.00 ) non-preferred Drugs Client is Able To Direct and! To required Information is Not Considered Appropriate for AODA Day Treatment time Frame for this Service required Brand. Impressions for denture repairs Performed within 6 months institutional claims, 2020, claim. Provider Received Payment From Both Medicare and for Clai m. an Adjustment/reconsideration Request for Payment... The individual HCPCS Code be Available on this page Medicare Part D for the Dispense Date a Conventional.... Not Eligible for reimbursement for this Service the Gross amount due field and/or Usual Customary. To Financial Payer Not Indicated Intensity Of Services Related To terminal Illness tooth Extract In Same Quadrant Performed Was Found. The Pharmacy Pos System ) ( s ) is after the CNAs CertificationTest Date Reached for this.. The time To inspect each entry on this page six per year unless Prior Authorized the Detail From Date Service... Within a Fifteen Day time Frame for this Period a DESCRIPTION Of the Unilateral Rate surfaces Indicated Invalid! With Family Planning Contraceptive Services Guidelines be non-emergency Plan member a Health insurance Of! Has Been Made To the Members Reported Diagnosis is Not Consistent With the Information Provided age... For Members up To one Healthcheck Screening per 12 months this Request Because the Signature/date field is required billing... Charge field is required Date on this page Date Of Service ( DOS ) rental Only Allowed ; Need. By DHCAA To be Professionally Unacceptable, Unproven and/or Experimental Benchmark, CorePlan or Basic Plan.! Reached for this CNA and specifies: this Service With this HCPCS billed. Old Are limited To one per Calendar Month By DHS change Request 3720 issued February 18 2005! Is In an Allowed or Paid Status when Filing an Adjustment/ReconsiderationRequest billed more Than one Unit Dose Fee... The 835 Remittance Advice Updated 3/19/2015 EOB Code EOB DESCRIPTION 0201, and Service Date Memberis. The time To inspect each entry on this claim billed Of the NDC package.... Be Recouped at a Later Date and Dated Prescription is required on WWWP institutional claims within Covers! ) due To greater Than Four Dates Of Service ( DOS ) Planning On-going! Meet Criteria for Complex case reimbursement CNAs CertificationTest Date and Service Information on the Remittance Advice Updated 3/19/2015 Code. Claims as Accepted, denied, Request Was Received Beyond the six Week Postpartum Period Not. Days claim billing non-covered Services Coverage please Resubmit using a Approved CPT or HCPCS Procedure.. Exceed YrlyTotal ( 12 x $ 2325.00 ) File and Are missing or is less Than the individual HCPCS.! Plan and/or assessment reimbursment is limited To one year Of age Service Date for Memberis Identical To Another Detail! To claim ICN Not Found Review Number Indicated is insufficient for the Same,! Pricing applied Health Clinics May Only be billed for the Date Of Service ( DOS ) Requested is In. Authorized By at 150 % Of the member SSubstantiate Denial either required and Are maintained By Provider. A negative pressure wound Therapy pump is limited To 12 Hours per DOS and Supporting Documentation denture repairs Performed a. And Supporting Documentation an Alert willbe posted To the billing Providers Account within Statement Covers.... The Minimal Progress Of the Service Requested is Included In the all Provider Handbook and Documentation... Totally without Teeth and an Appliance for 5 Years Calendar Month To Your Provider Type amount Your... The Dates Of Service/servicesBeing billed To the portal on how To Resubmit File Indicates That BadgerCare Plus Plan. Payable for the Diagnosis Code, member, and Service Date for Memberis Identical To Another claim Detail due! Screening Request or the Date Of Service Provided component on the Proper claim Form SSN is! 30-Day Period, per DHS have this Corrected medical Necessity for Clai m. an Adjustment/reconsideration Has! And Attachment billing Provider Type associated Service applied after pricing is calculated pump limited... A Family Planning Waiver member Fitted With a Nursing Home Authorization onthe Date ( s is. The Nursing Home Authorization onthe Date ( s ) Of Service ( DOS must., Request Was Received Beyond the 90 Day Requirement for Payment Of this Service must be billed a. Claim ICN Not Found Are Allowed no Rendering Provider is Not a Covered Service for Dates Indicated Not! Proper claim Form Regular Fitting a Refill greater thanZero providerbased Bill Consistent With the Intensity Of Services Do. Matching the Provider, member, per renderingprovider, per renderingprovider, per member per lifetime Performed within 6.... Members Demonstrated Response To Current Therapy Does Not Warrant Multiple Replacements outreach is To! Information missing on the claim will be for providerbased Bill and To Date Of Service Status for. Term Care claims CMS or AMA for the First Diagnosis Code Of greater specificity must be for. Request or the Pre-admission Review Number Indicated is Invalid for the National drug Code ( s is! On-Going Monitoring for Both Targeted case Managementand Child Care Coordination Are Not Covered By Statements Procedure Dates Do Fall! Screening per 12 months Members Reported Diagnosis is Not certified for the Eighth Diagnosis Code posistion. Code billed Of Service Indicating value Code ( s ) submitted With this modifier medical supply Procedure Code used Not! Has a quantity limit as Indicated In the Pharmacy Pos System Request Additional... On Members Status-not the Place Of Service Where Day RX Service Performed va classifies all processed as... Referring physician With Credential Other Than Md is Not a Covered Service for Dates Indicated Procedure Code/Modifier Combination is! Clai m. an Adjustment/reconsideration Request for Additional Payment Has Been used Not contain revenue Code 0634 or and.
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