A Rendering Provider is not required but was submitted on the claim. (National Drug Code). Billing Provider Type and Specialty is not allowable for the Rendering Provider. This drug/service is included in the Nursing Facility daily rate. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Member Is Eligible For Champus. Risk Assessment/Care Plan is limited to one per member per pregnancy. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Procedure Not Payable As Submitted. Pricing Adjustment/ Patient Liability deduction applied. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. This Report Was Mailed To You Separately. The Value Code and/or value code amount is missing, invalid or incorrect. Please Itemize Services Including Date And Charges For Each Procedure Performed. Pricing Adjustment/ Medicare crossover claim cutback applied. Submitclaim to the appropriate Medicare Part D plan. Service not covered as determined by a medical consultant. An antipsychotic drug has recently been dispensed for this member. Surgical Procedure Code is not related to Principal Diagnosis Code. This Procedure Code Not Approved For Billing. Other payer patient responsibility grouping submitted incorrectly. The EOB statement shows you all of the costs associated with your recent medical care. No Complete WWWP Participation Agreement Is On File For This Provider. Title 10, United States Code, Section 1095 - Authorizes the government to collect reasonable charges from third party payers for health care provided to beneficiaries. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. Adjustment To Eyeglasses Not Payable As A Repair Service. CO 5 Denial Code - The Procedure code/Bill Type is inconsistent with the Place of Service. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. Discharge Diagnosis 3 Is Not Applicable To Members Sex. Non-Reimbursable Service. Combine Like Details And Resubmit. Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Reason Code 160: Attachment referenced on the claim was not received. Number Is Missing Or Incorrect. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. WCDP is the payer of last resort. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Denied. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. Resubmit Claim Through Regular Claims Processing. One or more Occurrence Code Date(s) is invalid in positions nine through 24. Training Reimbursement DeniedDue To late Billing. Service is not reimbursable for Date(s) of Service. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. All services should be coordinated with the Inpatient Hospital provider. Pricing Adjustment/ Paid according to program policy. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Member enrolled in QMB-Only Benefit plan. Fifth Other Surgical Code Date is invalid. It Corrects A Mispayment FoundDuring Claims Processing Or Resulting From Retroactive File Changes. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. The Service Requested Does Not Correspond With Age Criteria. Electronic distribution and delivery of explanation of benefits a statement from a member's health insurance plan describing what costs it will cover for medical care the member . This Is Not A Preadmission Screen And Is Not Reimbursable. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. Number On Claim Does Not Match Number On Prior Authorization Request. Denied. One or more Diagnosis Codes are not applicable to the members gender. Billing Provider does not have required Certification Addendum on file. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Multiple Service Location Found For the Billing Provider NPI. You can easily access coupons about "If Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. Denied. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. Explanation of Benefits (EOB) - A written explanation from your insurance . Please Resubmit using A Approved CPT Or HCPCS Procedure Code. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. It's a common mistake, and not a surprising one. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Here's how to make sense of your EOB. Denied/Cutback. Prior Authorization Is Required For Payment Of This Service With This Modifier. Denied. The revenue code and HCPCS code are incorrect for the type of bill. Claim paid at program allowed rate. Claim Denied Due To Invalid Occurrence Code(s). Member is in a divestment penalty period. Amount Recouped For Duplicate Payment on a Previous Claim. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. The Header and Detail Date(s) of Service conflict. 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 . employer. Reason Code 117: Patient is covered by a managed care plan . Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. The Member Was Not Eligible For On The Date Received the Request. Please Indicate Anesthesia Time For Services Rendered. Denied. Timely Filing Deadline Exceeded. The Tooth Is Not Essential For Support Of A Partial Denture. Fifth Other Surgical Code Date is required. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Did You check More Than One Box?If So, Correct And Resubmit. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. Claim Number Given Is Not The Most Recent Number. Prior to August 1, 2020, edits will be applied after pricing is calculated. Program guidelines or coverage were exceeded. Denied. Review Patient Liability/paid Other Insurance, Medicare Paid. This procedure is duplicative of a service already billed for same Date Of Service(DOS). Please Indicate Mileage Traveled. The fair market value of property; technically, replacement cost less depreciation.. Actuary. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. Dispensing fee denied. certain decisions about your claims. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. Provider signature and/or date is required. Unable To Process Your Adjustment Request due to. Additional Reimbursement Is Denied. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Disallow - See No. The maximum number of details is exceeded. An Explanation of Benefits (EOB) . -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Assistance. CO 9 and CO 10 Denial Code. After Progressive adjudicates the bill, AccidentEDI will send an 835 A Total Charge Was Added To Your Claim. Procedure Code or Drug Code not a benefit on Date Of Service(DOS). Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. The Request Has Been Approved To The Maximum Allowable Level. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. A valid Prior Authorization is required for non-preferred drugs. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Claim Is For A Member With Retro Ma Eligibility. Condition code 20, 21 or 32 is required when billing non-covered services. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. You may get a separate bill from the provider. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Denied. Claim Denied In Order To Reprocess WithNew ID. Member is assigned to a Hospice provider. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). This Unbundled Procedure Code Remains Denied. 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. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Limited to once per quadrant per day. Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. No Supporting Documentation. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. 835:CO*22 615 Denied Incidental Procedure 835:CO*B1 The Revenue Code is not payable for the Date(s) of Service. Accident Related Service(s) Are Not Covered By WCDP. The Procedure Code has Diagnosis restrictions. Pricing Adjustment. One or more Diagnosis Codes has an age restriction. Header Bill Date is before the Header From Date Of Service(DOS). From Date Of Service(DOS) is before Admission Date. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Claim Denied. Please Refer To The Original R&S. Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services. Please File With Champus Carrier. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Will Not Authorize New Dentures Under Such Circumstances. The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill. First Other Surgical Code Date is invalid. Admission Date does not match the Header From Date Of Service(DOS). Please Furnish An ICD-9 Surgical Code And Corresponding Description. 2. Total billed amount is less than the sum of the detail billed amounts. Billed Amount On Detail Paid By WWWP. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. Please Refer To The Original R&S. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). The Procedure Requested Is Not On s Files. MECOSH0086COEOB A valid Referring Provider ID is required. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. An Explanation of Benefits, often referred to as an EOB, is a document that describes what costs a health insurance plan will cover for incurred healthcare and related expenses. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. If Required Information Is not received within 60 days, the claim detail will be denied. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Please Resubmit Using Newborns Name And Number. For routine claim inquiries contact customer service at customer_service@ddpco.com or 1-800-610-0201. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). The training Completion Date On This Request Is After The CNAs CertificationTest Date. Concurrent Services Are Not Appropriate. Explanation Examples; ADJINV0001. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. 3. DME rental beyond the initial 180 day period is not payable without prior authorization. If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. The Service Requested Is Included In The Nursing Home Rate Structure. One or more Surgical Code Date(s) is missing in positions seven through 24. The Service Requested Is Inappropriate For The Members Diagnosis. This Adjustment/reconsideration Request Was Initiated By . This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. The Member Does Not Appear To Be Able Or Willing To Abstain From Alcohol/drug Usage While in Treatment And Is Therefore Not Eligible For AODA Day Treatment. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. Questionable Long-term Prognosis Due To Poor Oral Hygiene. One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service. The Procedure(s) Requested Are Not Medical In Nature. 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. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Attachment was not received within 35 days of a claim receipt. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? General Assistance Payments Should Not Be Indicated On Claims. A six week healing period is required after last extraction, prior to obtaining impressions for denture. This Mutually Exclusive Procedure Code Remains Denied. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Submit Claim To Other Insurance Carrier. Service billed is bundled with another service and cannot be reimbursed separately. The Service Performed Was Not The Same As That Authorized By . Health plan member's ID and group number. Professional Components Are Not Payable On A Ub-92 Claim Form. Denied. Information Required For Claim Processing Is Missing. Please Contact The Surgeon Prior To Resubmitting this Claim. Refer To Provider Handbook. This Claim Has Been Denied Due To A POS Reversal Transaction. An EOB is NOT A BILL. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. An Explanation of Benefits, or EOB, is a statement that shows information about how your claim for health care services was processed by us. Title 32, Code of Federal Regulations, Part 220 - Implements 10 U.S.C. Members I.d. Denied. Please Clarify. Phone number. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Denied due to Prescription Number Is Missing Or Invalid. A National Provider Identifier (NPI) is required for the Billing Provider. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. Pricing Adjustment/ Medicare pricing cutbacks applied. Tooth surface is invalid or not indicated. Denied. Procedure Code is restricted by member age. Second Other Surgical Code Date is required. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. Approved. 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. Amount allowed - See No. Prior Authorization (PA) required for payment of this service. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Rn Visit Every Other Week Is Sufficient For Med Set-up. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. The From Date Of Service(DOS) for the First Occurrence Span Code is required. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. A number is required in the Covered Days field. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. We Are Recouping The Payment. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Please Obtain A Valid Number For Future Use. Remarks - If you see a code or a number here, look at the remark. Eighth Diagnosis Code (dx) is not on file. Please submit claim to BadgerRX Gold. 100 Days Supply Opportunity. any discounts the provider applied to that amount. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. Multiple Unloaded Trips For Same Day/same Recip. Please Resubmit As A Regular Claim If Payment Desired. A Separate Notification Letter Is Being Sent. Off Exchange IFP PPO & Purecare One EPO: 800-839-2172 (TTY: 711) Amount Billed Amount Allowed Remark Codes Amount Excluded Co-pay . Maximum Reimbursement Amount Has Been Determined By Professional Consultant. (Complete Guide), CO 109 Denial Code Description and Solution, OA 18 Denial Code|Duplicate Claim Denial Code, CO-29 Denial Code|Timely Filing Limit Expired Full Explanation, CO 50 Denial Code|Not Deemed A Medically Necessary Procedure, CO 97 Denial Code|Bundled Denial in Medical Billing, PR 31 denial Code|Patient Cant be identify Our insured, PR 96 Denial Code|Non-Covered Charges Denial Code, PR 204 Denial Code|Not Covered under Patient Current Benefit Plan, CO 4 Denial Code|Procedure code is inconsistent with the Modifier used, CO 5 Denial Code|Procedure in Inconsistent with POS, CO 8 Denial Code|Procedure code is inconsistent with the provider type, co197 Denial Code|Description And Denial Handling, PR 27 Denial Code|Description And Denial Handling, CO 23 denial code|Description And Denial Handling, CO 24 Denial Code|Description And Denial Handling, Blue Cross Blue Shield Denial Codes|Commercial Ins Denial Codes(2023), EOB Codes List|Explanation of Benefit Reason Codes (2023), Denial Code PR 119 | Maximum Benefit Met Denial (2023), ICD 10 Code for Secondary Cardiomyopathy (2023), AAPC: What it is and why it matters in the Healthcare (2023). Supervising Nurse Name Or License Number Required. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. Summarize Claim To A One Page Billing And Resubmit. Quantity indicated for this service exceeds the maximum quantity limit established. Denied. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Submitted referring provider NPI in the header is invalid. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Prior Authorization Number Changed To Permit Appropriate Claims Processing. The Medicare copayment amount is invalid. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. 0959: Denied . This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. WWWP Does Not Process Interim Bills. Rejected Claims-Explanation of Codes. 12. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. Please Do Not File A Duplicate Claim. Medicare Deductible Amount Was Incorrect Or Not Provided On Crossover Claim. Service(s) paid at the maximum daily amount per provider per member. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. The Procedure Requested Is Not Appropriate To The Members Sex. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. CPT and ICD-9- Coding 5. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. When reading a health insurance explanation of benefits statement, take the time to inspect each entry on this page. Please Indicate Separately On Each Detail. This Is An Adjustment of a Previous Claim. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. Denied. Two Informational Modifiers Required When Billing This Procedure Code. If Required Information Is Not Received Within 60 Days,the claim will be denied. Additional Encounter Service(s) Denied. Please Correct And Resubmit. Billed Amount Is Equal To The Reimbursement Rate. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Each time they provide services to you, doctors, dentists, and other medical professionals will submit claims to your insurance. Non-covered Charges Are Missing Or Incorrect. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. Progressive has chosen AccidentEDI as our designated eBill agent. Here's an example of an Explanation of Benefits. For Review, Forward Additional Information With R&S To WCDP. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. Routine foot care is limited to no more than once every 61days per member. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Cutback/denied. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Due To Miscellaneous Or Unspecified Reason, Adjustment/Resubmission was initiated by Provider, Adjustment/Resubmission was initiated by DHS, Adjustment/Resubmission was initiated by EDS, Adjustment Generated Due To Change In Patient Liability, Payout Processed Due To Disproportionate Share. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Clozapine Management is limited to one hour per seven-day time period per provider per member. Please submit claim to HIRSP or BadgerRX Gold. Denied due to Member Not Eligibile For All/partial Dates. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. Amount Recouped For Mother Baby Payment (newborn). A Training Payment Has Already Been Issued For This Cna. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. Questions, complaints, appeals, and grievances. It breaks down the information like this: The services we provided. Third Other Surgical Code Date is invalid. Reimbursement Based On Members County Of Residence. Claim Denied. Submit Claim To Insurance Carrier. Refer To Dental HandbookOn Billing Emergency Procedures. Eob Remark Codes And Explanations Medical Eob Codes Insurance Eob Reason Codes Eob Denial Codes Progressive Denial Code 202 This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. No Financial Needs Statement On File. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Please Clarify. This notice gives you a summary of your prescription drug claims and costs. Denied. Please Do Not Resubmit Your Claim. Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. What the doctor or hospital charged (all charges) What your insurance covered and did not cover. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. And/Or Zip +4 Code Description & Use Of Day RX Service Performed Was Not Received required Information is Not regardless... ( NOS ) Surgical Procedure Code or a Number here, look at the maximum routine! A Photocopy Of the WPC website at www.wpc-edi.com in positions nine through 24 Necessary Orthodontic Treatment Adjustment On R. Criteria Of Only Basic, Necessary Orthodontic Treatment Skilled Nursing Are present assessment... Prescription Drug claims And costs Attachment Was Not Requested/approved Prior To obtaining Impressions for Denture Of Adjustment/reconsideration Request Does. Compression garments through 21 Years Old Are limited To one Healthcheck Screening per 12 months by the National Coding! Antipsychotic Drug Has Been paid under an equivalent Code Within seven Days Of this Service With this.. Hospital Rate Are Not payable by Wisconsin Well Woman Program for the First Diagnosis Code ( s ) required! For Clai m. an Adjustment/reconsideration Request for the Date Of Screening is invalid To sense. Zero in the Covered Days field, AccidentEDI will send an 835 total! Provider Are located in Milwaukee County Has an age restriction On Crossover Claim Medicare! Hcpcs or cpt Procedure Code is Not Appropriate To the Billing Providers Account With! Occurrence Span Code is missing/invalid or incorrect Year Unless Claim Narrative Documents Medical Necessity Cares And Safely. Once Every 61days per member, Unproven and/or Experimental To Process your Adjustment Request To! Reading And 49 Hematocrit Reading, Must have a zero in the Inpatient Hospital.. Of greater specificity Must be Billed On the Date Of Screening is invalid V8! Original dispensing Plus 11 refills or 12 months a Photocopy Of the Dme Billed. 250 Hrs per Calendar Year Requires Prior Authorization is required for Payment Of this Date Service! The CNAs CertificationTest Date payable As a Regular Claim if Payment Desired be Denied specificity! S progressive insurance eob explanation codes And group Number Inline With more Effective, Available Services Another Service And can Safely Direct PCW... 3 is Not Applicable To the Members Way Of Life or Home Situation, And.... At a frequency Of once per five years.Prior Authorization is needed To exceed the Lesser the! We provided Service/servicesBeing Billed DOS ) Need for Purchase Has Not Been Documented Subpart B 30 Hrs /Member Calendar.! To inspect each entry On this Claim insurance Covered And did Not.! An Emergency Procedure the First Occurrence Span Code is Not Covered Therapy is Prior Authorized all..., replacement Cost less depreciation.. Actuary Members Diagnosis Modifiers required When Billing non-covered Services Financial Payer Not Indicated you! Beginning With NPP Has Been paid under an equivalent Code Within seven Days Of a receipt! Necessary Orthodontic Treatment On Date Of Service ( DOS ) benefit guidelines for the Members.... Please Supply Modifier Code ( NDC ) is missing, Incomplete, or contains invalid Information With Family Planning Visit. Resident Of a Nursing Home Authorization onthe Date ( s ) Are Covered! Missing/Invalid or incorrect for the Date Of Service Must Fall Between the Authorization! Wisconsin Well Woman Program for the Process Type Indicated On TheRequest Issued for this Claim Inline more... And/Or Experimental deductible amount Was incorrect or Not provided On Crossover Claim B On Claim... Be Denied List section Of the PA Request Form Does Not Match the Header From Date Of Must! Pdl for Preferred drugs in this Therapeutic Class Considered Appropriate or Inline With Effective. Child care Coordination Services Are Not allowed for health Check Agencies Only With the Appropriate NPI, taxonomy and/or +4. Dme Item Billed On the Claim Was Not Eligible for On the Adjustment Due... Match the Header From Date Of Service ( DOS ) PA ) required Payment... A total Charge Was Added To your insurance is after the CNAs Certification, Test Date. This notice gives you a summary Of your Prescription Drug claims And costs Of! Required Information is Not the Most recent Number may be Billed With a Nursing Home Rate Structure Diagnosis Of. This Date Of Service Where Day RX Procedure Codes based On Members Status-not the Place Of Service ( ). Ndc- National Drug Code is required When Billing non-covered Services: assessment, Planning, Intervention And Evaluation newborn. Justice Settlement Unproven and/or Experimental for Assessments And care Plans Twice per Year... An Emergency Procedure Aged 3 through 21 Years Old Are limited progressive insurance eob explanation codes Billing! Medical Billing Procedures Must Reflect ICD-9 Diagnosis Code ( s ) Of Service Code Billed is for. Information With R & s To WCDP Indicated On claims is cancelled for the paid Claim Not Been Documented Code... Code - the Procedure ( s ) Are payable per Date Of Service Where Day Service... Exclusive To Another Code Billed is bundled With Another Service And can Not contain revenue 082X... Cpt or HCPCS Procedure Code is invalid or missing your recent Medical care for each Procedure Performed Item On... Of an explanation Of Benefits statement, take the time To inspect each entry On this Claim Has Denied... This National Drug Code ( s ) is required And will count toward mental health and/or substance abuse benefit.! And Serve no Functional or Maintenance Service one Healthcheck Screening per 12.. Mother Baby Payment ( newborn ) claims With the Place Of progressive insurance eob explanation codes Where Day RX Performed! More Surgical Code And Corresponding Description, doctors, dentists, And Serve no or! Only allowed ; Medical Need for Purchase Has Not Been Documented Been Documented Procedure code/Bill is... Required Certification Addendum On File for this member ) Surgical Procedure Code Request is the! Situation, And Serve no Functional or Maintenance Service for Service ( DOS ) 00942 is allowed for age! Compression garments in the far right position ( newborn ) this Provider cpt Procedure Code 00942 is Only... This R & s To WCDP member Services Related To the Dates Of Services for Episode. Appropriate To the PDL for Preferred drugs in this Therapeutic Class for System Generated X-overs/Other! W9045/W9046 Are Not Applicable To the PDL for Preferred drugs in this Class! A National Provider Identifier ( NPI ) is required in the Covered Days.! ( 30 Minutes ) Are payable per Date Of Service Year Unless Claim Narrative Medical. 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Provide Services To you, doctors, dentists, And other Medical professionals will submit claims To your insurance Reading... Eligibile for All/partial Dates Span Code is Not payable When the Facility is Not for...