progressive insurance eob explanation codes

According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Denied. Different Drug Benefit Programs. Documentation Does Not Justify Medically Needy Override. Denied. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Denied as duplicate claim. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. Your health plan's Customer Service Number may be near the plan's logo or on the back of your EOB. Pricing Adjustment/ Spenddown deductible applied. Submit Claim To Insurance Carrier. Denied. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. The Maximum Prior Authorized Service Limitation Or Frequency Allowance Has Been Exceeded. 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. Denied. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. This Adjustment Was Initiated By . Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Rebill On Pharmacy Claim Form. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Claim Denied. MECOSH0086COEOB Off Exchange IFP PPO & Purecare One EPO: 800-839-2172 (TTY: 711) Amount Billed Amount Allowed Remark Codes Amount Excluded Co-pay . Endurance Activities Do Not Require The Skills Of A Therapist. Covered By An HMO As A Private Insurance Plan. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Reimbursement For This Service Has Been Approved. An explanation of benefits is a document that explains how your insurance processed the claim for the services you received. Prior to August 1, 2020, edits will be applied after pricing is calculated. This claim is a duplicate of a claim currently in process. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Claim: The claim will usually contain the itemized bill, statements, and charges for your visit. Disallow - See No. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. The maximum number of details is exceeded. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. Wk. Enter ZIP Code. Denied by Claimcheck based on program policies. Speech Therapy Is Not Warranted. Please Verify That Physician Has No DEA Number. Title 32, Code of Federal Regulations, Part 220 - Implements 10 U.S.C. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. Member Name Missing. A Payment Has Already Been Issued For This SSN. Please Use This Claim Number For Further Transactions. Billing Provider Type and Specialty is not allowable for the Place of Service. The Existing Appliance Has Not Been Worn For Three Years. Procedure code - Code(s) indicate what services patient received from provider. If A CNA Obtains his/her Certification After Theyve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To . A Second Surgical Opinion Is Required For This Service. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Early Refill Alert. Claim Detail Is Pended For 60 Days. Billed Amount On Detail Paid By WWWP. NDC is obsolete for Date Of Service(DOS). Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Pricing Adjustment/ Payment reduced due to benefit plan limitations. The Revenue Code is not payable for the Date(s) of Service. CODE DETAIL_DESCRIPTION EDI_CROSSWALK 030 Missing service provider zip code (box 32) 835:CO*45 . Reimbursement Is At The Unilateral Rate. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. You may get a separate bill from the provider. Please submit claim to HIRSP or BadgerRX Gold. Please Provide The Type Of Drug Or Method Used To Stop Labor. The Rendering Providers taxonomy code in the header is not valid. Claim Reduced Due To Member/participant Spenddown. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. (800) 297-6909. Other Medicare Managed Care Response not received within 120 days for providerbased bill. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Denied. The Request Has Been Back datedto Date of Receipt. Prescription Date is after Dispense Date Of Service(DOS). Modifier Submitted Is Invalid For The Member Age. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Here's how to make sense of your EOB. Procedure Dates Do Not Fall Within Statement Covers Period. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. Pharmaceutical care code must be billed with a valid Level of Effort. No Matching, Complete Reporting Form Is On File For This Client. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Effective August 1 2020, the new process applies coding . An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. This Incidental/integral Procedure Code Remains Denied. Denied. (888) 750-8783. V2781 JA - Progressive J Plastic. Member has commercial dental insurance for the Date(s) of Service. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Number Is Missing Or Incorrect. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. Previously Denied Claims Are To Be Resubmitted As New Day Claims. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. Timely Filing Request Denied. Please adjust quantities on the previously submitted and paid claim. Detail To Date Of Service(DOS) is required. (part JHandbook). Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. It shows: Health care services you received; How much your health insurance plan covered; How much you may owe your provider; Steps you can take to file an appeal if you disagree with our coverage decision Principle Surgical Procedure Code Date is missing. The Medical Need For Some Requested Services Is Not Supported By Documentation. 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. Individual Audiology Procedures Included In Basic Comprehensive Audiometry. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. Please Indicate Anesthesia Time For Services Rendered. Denied. Denied due to Claim Contains Future Dates Of Service. 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. 0394 MEDICARE CO-INSURANCE AMOUNT MISSING. This National Drug Code (NDC) is not covered. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. The Service Performed Was Not The Same As That Authorized By . MassHealth List of EOB Codes Appearing on the Remittance Advice. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Please Clarify. Look at the "provider of services" and "place of service," listed on the first EOB in this post as "Mills Hospital" and "outpatient.". Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Pricing Adjustment/ Medicare benefits are exhausted. Service(s) Denied By DHS Transportation Consultant. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Unable To Process Your Adjustment Request due to Provider Not Found. This Procedure Is Limited To Once Per Day. Pricing AdjustmentUB92 Hospice LTC Pricing. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. EOBs are created when an insurance provider processes a claim for services received. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. A valid Prior Authorization is required for Brand Medically Necessary Drugs. Subsequent surgical procedures are reimbursed at reduced rate. Physical Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. is unable to is process this claim at this time. 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 Member Is Enrolled In An HMO. Denied. Denied. Claim Denied. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Offer. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. 032 eob/carr.cd mismatch eob(s) attached/carrier code does not match 1 251 n4 286 033 need eob-carr/recip. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Denied. Up to a $1.10 reduction has been applied to this claim payment. The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). Denied due to Member Not Eligibile For All/partial Dates. Billing Provider ID is missing or unidentifiable. 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. You Must Either Be The Designated Provider Or Have A Refer. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Nursing Home Visits Limited To One Per Calendar Month Per Provider. Please Contact The Surgeon Prior To Resubmitting this Claim. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Claim Has Been Adjusted Due To Previous Overpayment. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Amount Recouped For Mother Baby Payment (newborn). The revenue code has Family Planning restrictions. Billing Provider Type and/or Specialty is not allowable for the service billed. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. The Billing Providers taxonomy code is invalid. The Travel component for this service must be billed on the same claim as the associated service. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. Other Coverage Code is missing or invalid. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Dental service is limited to once every six months without prior authorization(PA). Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. Denied. Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849. This Claim Has Been Manually Priced Based On Family Deductible. Procedure Code Changed To Permit Appropriate Claims Processing. The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty. If required information is not received within 60 days, the claim will be. Denied. Only two dispensing fees per month, per member are allowed. A Payment For The CNAs Competency Test Has Already Been Issued. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Please Contact Your District Nurse To Have This Corrected. Diagnosis Treatment Indicator is invalid. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. 10. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. The Procedure Requested Is Not Appropriate To The Members Sex. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. PIP coverage protects you regardless of who is at fault. Denied/Cutback. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Drug(s) Billed Are Not Refillable. This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. The quantity billed of the NDC is not equally divisible by the NDC package size. This is a duplicate claim. Refer To Dental HandbookOn Billing Emergency Procedures. Claim Denied. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. A valid procedure code is required on WWWP institutional claims. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Please Submit On The Cms 1500 Using The Correct Hcpcs Code. Procedure Code and modifiers billed must match approved PA. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. An NCCI-associated modifier was appended to one or both procedure codes. One or more Surgical Code(s) is invalid in positions six through 23. PA required for payment of this service. Denied. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Discharge Diagnosis 3 Is Not Applicable To Members Sex. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. Request Denied. Multiple Referral Charges To Same Provider Not Payble. First Other Surgical Code Date is invalid. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. Contact Provider Services For Further Information. Denied. CPT is registered trademark of American Medical Association. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Cutback/denied. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. Claim Denied. Rendering Provider Type and/or Specialty is not allowable for the service billed. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. DME rental beyond the initial 180 day period is not payable without prior authorization. The Sixth Diagnosis Code (dx) is invalid. . Please Correct And Resubmit. Seventh Diagnosis Code (dx) is not on file. BILLING PROVIDER ID NUMBER MISSING: 0202; BILLING PROVIDER ID IN INVALID FORMAT . Offer. Denied. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. [1] The EOB is commonly attached to a check or statement of electronic payment. A six week healing period is required after last extraction, prior to obtaining impressions for denture. The National Drug Code (NDC) has an age restriction. Requests For Training Reimbursement Denied Due To Late Billing. A Hospital Stay Has Been Paid For DOS Indicated. Services on this claim were previously partially paid or paid in full. Claim Is Being Reprocessed Through The System. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Not all claims generate . Attachment was not received within 35 days of a claim receipt. No Action Required on your part. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Contacting WorkCompEDI.com. Resubmit charges for covered service(s) denied by Medicare on a claim. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. When the insurance company gets the claim, they will evaluate the claim, create an Explanation of Benefits (sometimes referred to as an EOB) and send it to you in the mail. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. Account summary A brief snapshot of vital information, including: Your name and address. A dispense as written indicator is not allowed for this generic drug. The Primary Diagnosis Code is inappropriate for the Procedure Code. Is Unable To Process This Request Because The Signature/date Field Is Blank. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. Ninth Diagnosis Code (dx) is not on file. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Second Other Surgical Code Date is invalid. Other Medicare Part B Response not received within 120 days for provider basedbill. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Billing Provider is not certified for the Dispense Date. Unable To Reach Provider To Correct Claim. Service Denied. The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. Third Other Surgical Code Date is required. Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. 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. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. Abortion Dx Code Inappropriate To This Procedure. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . Pricing Adjustment. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). 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.

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