Refer To Provider Handbook. Service Denied/cutback. Exceeds The 35 Treatment Days Per Spell Of Illness. Denied due to Per Division Review Of NDC. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. Claim Denied. Incidental modifier was added to the secondary procedure code. Sign up for electronic payments and statements before it's your turn. An approved PA was not found matching the provider, member, and service information on the claim. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. Routine foot care is limited to no more than once every 61days per member. This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Denied. It breaks down the information like this: The services we provided. 128 EOB required The primary carrier's explanation of benefits is necessary to consider these services. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. Reimbursement For This Service Is Included In The Transportation Base Rate. Date of services - the date you received the care. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. If the insurance company or other third-party payer has terminated coverage, the provider should A six week healing period is required after last extraction, prior to obtaining impressions for denture. Please Reference Payment Report Mailed Separately. Documentation Does Not Justify Fee For ServiceProcessing . Cutback/denied. The service is not reimbursable for the members benefit plan. The header total billed amount is required and must be greater than zero. Medically Unbelievable Error. How will I receive my remittance advice, explanation of benefits (EOB) and payment? Billing Provider ID is missing or unidentifiable. Claim or Adjustment received beyond 365-day filing deadline. (a) An insurance carrier shall take final action after conducting bill review on a complete medical bill, or determine to audit the medical bill in accordance with 133.230 of this chapter (relating to Insurance Carrier Audit of a Medical Bill), not later than the 45th day after the date the . Services Requested Do Not Meet The Criteria for an Acute Episode. 4. Billed Procedure Not Covered By WWWP. Reduction To Maintenance Hours. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. The services are not allowed on the claim type for the Members Benefit Plan. Other Payer Coverage Type is missing or invalid. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Member has commercial dental insurance for the Date(s) of Service. Procedure code - Code(s) indicate what services patient received from provider. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Contact Wisconsin s Billing And Policy Correspondence Unit. All Requests Must Have A 9 Digit Social Security Number. Your 1099 Liability Has Been Credited. So, what is an EOB? Service Denied. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. A Payment Has Already Been Issued For This SSN. Req For Acute Episode Is Denied. Condition code 20, 21 or 32 is required when billing non-covered services. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. A National Provider Identifier (NPI) is required for the Billing Provider. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Quantity Billed is restricted for this Procedure Code. 2. This claim is eligible for electronic submission. Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. See Physicians Handbook For Details. Denied due to Member Is Eligible For Medicare. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. No matching Reporting Form on file for the detail Date Of Service(DOS). Edentulous Alveoloplasty Requires Prior Authotization. Services billed are included in the nursing home rate structure. This Procedure Is Limited To Once Per Day. Header From Date Of Service(DOS) is after the date of receipt of the claim. Claim Denied. Assistance. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. You may get a separate bill from the provider. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Please Disregard Additional Information Messages For This Claim. A Primary Occurrence Code Date is required. Claims With Dollar Amounts Greater Than 9 Digits. your coverage was still in effect . The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. VA classifies all processed claims as accepted, denied, or rejected. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Title 32, Code of Federal Regulations, Part 220 - Implements 10 U.S.C. Member is not Medicare enrolled and/or provider is not Medicare certified. Third Other Surgical Code Date is required. The Procedure(s) Requested Are Not Medical In Nature. 140 only revenue codes 300 or 310 are allowed on outpatient claims when billing lab Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. Denied. Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). CNAs Eligibility For Training Reimbursement Has Expired. Patient Demographic Entry 3. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Allstate insurance code: 37907. . Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. This claim has been adjusted due to Medicare Part D coverage. Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. EPSDT/healthcheck Indicator Submitted Is Incorrect. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. CNAs Eligibility For Nat Reimbursement Has Expired. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Claim Denied. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. This limitation may only exceeded for x-rays when an emergency is indicated. Please Review Remittance And Status Report. Please Furnish A UB92 Revenue Code And Corresponding Description. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. The EOB is an overview of medical services you received. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Please Complete Information. Prescriber ID Qualifier must equal 01. They might also make a digital copy available . If You Have Already Obtained SSOP, Please Disregard This Message. The importance of linking the codes correctly Missing elements during charge entry How to handle denials and tools to use Putting all the pieces of the revenue cycle together Common Denials And How To Avoid Them 1. The Member Is School-age And Services Must Be Provided In The Public Schools. Please Correct And Resubmit. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Denied. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? This Procedure Is Denied Per Medical Consultant Review. To allow for Medicare Pricing correct detail denials and resubmit. Partial Payment Withheld Due To Previous Overpayment. Diagnosis Treatment Indicator is invalid. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Unable To Process Your Adjustment Request due to Member ID Not Present. Prescribing Provider UPIN Or Provider Number Missing. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Attachment was not received within 35 days of a claim receipt. Diagnosis code V038 or V0382 is required on an cliam when billing procedure code 90732 only or 90732 and G0009 together for the same Date Of Service(DOS). According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. Please Obtain A Valid Number For Future Use. Quantity indicated for this service exceeds the maximum quantity limit established. The dental procedure code and tooth number combination is allowed only once per lifetime. Multiple Referral Charges To Same Provider Not Payble. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Name And Complete Address Of Destination. Per Information From Insurer, Claims(s) Was (were) Paid. Correct Claim Or Submi Paper Claim Noting That Verification Has Occurred. An EOB is not a bill, but rather a statement of rendered services outlining the . Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. Member last name does not match Member ID. This procedure is age restricted. You can easily access coupons about "Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. One or more Diagnosis Codes has an age restriction. Reimbursement rate is not on file for members level of care. READING YOUR EXPLANATION OF BENEFITS (EOB) go.cms . Claim Denied For Future Date Of Service(DOS). Please watch future remittance advice. NFs Eligibility For Reimbursement Has Expired. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. OTHER INSURANCE AMOUNT GREATER THAN OR . Member is enrolled in Medicare Part B on the Date(s) of Service. Denied. Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date. This Unbundled Procedure Code Remains Denied. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Co. 609 . CO 13 and CO 14 Denial Code. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. Please Correct And Resubmit. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. A statistician who computes insurance risks and premiums. EOBs are created when an insurance provider processes a claim for services received. Modifier invalid for Procedure Code billed. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. CPT/HCPCS codes are not reimbursable on this type of bill. Medicare Disclaimer Code invalid. Do not leave blank fields between the multiple occurance codes. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Denied. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. When reading a health insurance explanation of benefits statement, take the time to inspect each entry on this page. Multiple Requests Received For This Ssn With The Same Screen Date. First Other Surgical Code Date is invalid. Will Not Authorize New Dentures Under Such Circumstances. Claim Denied. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. Rqst For An Acute Episode Is Denied. eob eob_message 1 provider type inconsistent with claim type . Service is not reimbursable for Date(s) of Service. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). Denied. Claim Denied Due To Invalid Occurrence Code(s). Denied. A Version Of Software (PES) Was In Error. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. The Member Is Only Eligible For Maintenance Hours. HCPCS Procedure Code is required if Condition Code A6 is present. 0959: Denied . Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. Indicator for Present on Admission (POA) is not a valid value. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. Discharge Diagnosis 3 Is Not Applicable To Members Sex. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. Please Correct and Resubmit. Good Faith Claim Denied Because Of Provider Billing Error. AAA insurance code: 71854. Claim Number Given Is Not The Most Recent Number. Reimbursement Is At The Unilateral Rate. All services should be coordinated with the primary provider. The National Drug Code (NDC) is not payable for the Provider Type and/or Specialty. Nine Digit DEA Number Is Missing Or Incorrect. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Denied. This procedure is limited to once per day. No Action On Your Part Required. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. Prospective DUR denial on original claim can not be overridden. Adjustment Requested Member ID Change. The Rendering Providers taxonomy code in the header is invalid. This Service Is Included In The Hospital Ancillary Reimbursement. Header From Date Of Service(DOS) is invalid. Transplants and transplant-related services are not covered under the Basic Plan. Header Bill Date is before the Header From Date Of Service(DOS). Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Yes, we know this is confusing. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. Pricing Adjustment/ Maximum Allowable Fee pricing used. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. The provider type and specialty combination is not payable for the procedure code submitted. Separate reimbursement for drugs included in the composite rate is not allowed. Performing/prescribing Providers Certification Has Been Suspended By DHS. As A Reminder, This Procedure Requires SSOP. Previously Denied Claims Are To Be Resubmitted As New-day Claims. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. Result of Service code is invalid. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Denied. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. Covered By An HMO As A Private Insurance Plan. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. HMO Capitation Claim Greater Than 120 Days. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Pricing Adjustment/ Prescription reduction applied. Reason Code 116: Benefit maximum for this time period or occurrence has been reached. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. Please Refer To The All Provider Handbook For Instructions. Claim Denied. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. A National Drug Code (NDC) is required for this HCPCS code. The quantity billed of the NDC is not equally divisible by the NDC package size. Referring Provider ID is invalid. Surgical Procedure Code billed is not appropriate for members gender. Per Information From Insurer, Claim(s) Was (were) Not Submitted. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Denied as duplicate claim. Procedure Code is restricted by member age. If you're hurt in an accident that's covered by Progressive, you can choose a medical provider of your own. Admit Date and From Date Of Service(DOS) must match. Denied. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Service Not Covered For Members Medical Status Code. Replacement and repair of this item is not covered by L&I. NULL CO 96, A1 N171 Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated. Incidental modifier is required for secondary Procedure Code. There is no action required. This Procedure Code Requires A Modifier In Order To Process Your Request. Service(s) exceeds four hour per day prolonged/critical care policy. This Is A Duplicate Request. The Fourth Occurrence Code Date is invalid. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Denied/Cutback. The Fifth Diagnosis Code (dx) is invalid. Claim Is Being Reprocessed Through The System. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). The total billed amount is missing or is less than the sum of the detail billed amounts. Third modifier code is invalid for Date Of Service(DOS). A quantity dispensed is required. Request Denied Because The Screen Date Is After The Admission Date. is unable to is process this claim at this time. Election Form Is Not On File For This Member. The General's NAIC number is the five-digit code given by the National Association of Insurance Commissioners (NAIC), which assigns numbers to authorized insurance providers in order to track customer complaints and ethics violations across state lines. Look at the "provider of services" and "place of service," listed on the first EOB in this post as "Mills Hospital" and "outpatient.". The Service Requested Is Not Medically Necessary. Please Correct And Resubmit. All services should be coordinated with the Inpatient Hospital provider. According to Mindy Stadel, a relationship manager with Pivot Health Group, it's critical for health care consumers to familiarize themselves with key terms that are used on EOBs and other important insurance documents. This Is Not A Good Faith Claim. Limited to once per quadrant per day. Denied. The Duration Of Treatment Sessions Exceed Current Guidelines. A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. This Diagnosis Code Has Encounter Indicator restrictions. Denied. The Resident Or CNAs Name Is Missing. These Services Paid In Same Group on a Previous Claim. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Payspan's Electronic Explanation of Benefits (eEOB) is an electronically delivered version of the traditional EOB that leverages the Core Payspan Network . Denied. The Diagnosis Code is not payable for the member. Service billed is bundled with another service and cannot be reimbursed separately. Pricing Adjustment/ Repackaging dispensing fee applied. Non-preferred Drug Is Being Dispensed. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Prior Authorization is required to exceed this limit. This Adjustment/reconsideration Request Was Initiated By . Claim Detail Denied Due To Required Information Missing On The Claim. Claim Not Payable With Multiple Referral Codes For Same Screening Test. Medical Billing and Coding Information Guide. Medical Payments and Denials. One Visit Allowed Per Day, Service Denied As Duplicate. A covered DRG cannot be assigned to the claim. Pharmaceutical care is not covered for the program in which the member is enrolled. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Explanation of Benefits - Standard Codes - SAIF . 2 above. Member is not enrolled in the program submitted in the Plan ID field for the Dispense Date Of Service(DOS) or an invalid Plan ID was submitted. The Revenue Code is not payable for the Date Of Service(DOS). Revenue code is not valid for the type of bill submitted. Multiple Providers Of Treatment Are Not Indicated For This Member. 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 . Denied. Denied. Here is what you'll typically find on your EOB: 1. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Reimbursement limit for all adjunctive emergency services is exceeded. Pricing Adjustment/ Medicare pricing cutbacks applied. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. Denied. . Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Service Denied. This claim has been adjusted due to a change in the members enrollment. 24260 Progressive insurance code: 24260. Denied due to Services Billed On Wrong Claim Form. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Denied due to NDC Is Not Allowable Or NDC Is Not On File. (800) 297-6909. Only two dispensing fees per month, per member are allowed. . Occurrence Codes 50 And 51 Are Invalid When Billed Together. Only One Ventilator Allowed As Per Stated Condition Of The Member. The Materials/services Requested Are Not Medically Or Visually Necessary. (888) 750-8783. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. Please Correct And Re-bill. The Service Requested Was Performed Less Than 3 Years Ago. 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. Claim contains duplicate segments for Present on Admission (POA) indicator. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. Claim Is Being Reprocessed, No Action On Your Part Required. A Rendering Provider is not required but was submitted on the claim. Denied due to The Members Last Name Is Incorrect. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Claims Cannot Exceed 28 Details. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Along with the EOB, you will see claim adjustment group codes. Care Does Not Meet Criteria For Complex Case Reimbursement. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. An antipsychotic drug has recently been dispensed for this member. The Primary Diagnosis Code is inappropriate for the Revenue Code. The Maximum Allowable Was Previously Approved/authorized. Documentation Does Not Justify Reconsideration For Payment. Note: This PA Request Has Been Backdated A Maximum Of 3 Weeks Prior To Its First Receipt By EDS, Based Upon Difficulty In Obtaining The Physicians Written Prescription. (National Drug Code). Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Please Supply NDC Code, Name, Strength & Metric Quantity. The NAIC number is issued by the National Association of . One or more Occurrence Span Code(s) is invalid in positions three through 24. Rqst For An Acute Episode Is Denied. Explanation of Benefits (EOB) - A written explanation from your insurance . Request Denied Due To Late Billing. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Modification Of The Request Is Necessitated By The Members Minimal Progress. Provider is not eligible for reimbursement for this service. It is a duplicate of another detail on the same claim. Pricing Adjustment/ Payment reduced due to benefit plan limitations. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. Rebill On Pharmacy Claim Form. Critical care in non-air ambulance is not covered. Dental service is limited to once every six months. PNCC Risk Assessment Not Payable Without Assessment Score. Invalid modifier removed from primary procedure code billed. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). Claim Must Indicate A New Spell Of Illness And Date Of Onset. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Members I.d. 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. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. The NAIC code is found on your . PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Please Use This Claim Number For Further Transactions. Abortion Dx Code Inappropriate To This Procedure. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. This service is not covered under the ESRD benefit. Personal injury protection (PIP), also known as no-fault insurance, covers medical expenses and lost wages of you and your passengers if you're injured in an accident. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. With Accident Forgiveness (not available in CA, CT, and MA) on your GEICO auto insurance policy, your insurance rate won't go up as a result of your first at-fault accident.. Actual Cash Value. Reimbursement Based On Members County Of Residence. Modification Of the online Handbook for claims submission requirements for compression garments has. 35 Treatment Days Per Spell Of Illness And Date Of Service ( DOS ) Costs for Sterilization Charges... Any necessary repair is Included in the Members Benefit Plan Limitations at AWP ( Average Wholesale )... Per Member/Provider/Date Of Service ( DOS ) ( s ) is After the Date Of Service DOS! Detail Denials And Resubmit Appropriate Service Elsewhere, Therefore Day Treatment Private HMO or HMP coverage is allowed once!, claim ( s ) Of Service Billed on the previously Paid X-ray claim for services received Individual And Pncc! Or 310 Are allowed Per Day prolonged/critical care policy Your turn Denied claims Are To Resubmitted... Ndc package size for Immunotherapy Service Included in the composite rate is not To. Transportation Base rate Core Plan or Basic Plan Code is not payable when Billed on Adjustment. 365 Days RA/EOMB And claim Dates and/or Charges Do not Match assistant Surgeon With Modifier 80 Treatment Days Per Per... Surgical Procedure Code in the DMS Index Functional Regression has Occurred After Date Approved National Provider (... Follow-Through, Based on Diagnosis Of Long-standing Nature, And Psyche RedUction amounts Basis. 0821, 0825 or 0829, HCPCS Code required Prior Authorization is required for this time period or Occurrence been. Codes 0110 ( N6 ) And Payment hour limitation on evaluation/assessment services in a timely fashion combination Vaccine Code not. Of bill submitted Billed With valid routine Foot care Procedures Must Be Billed valid... And on the claim not valid for the Members Needs Be adjusted a! According To Our Records Indicate this Provider is not payable on the claim Part. Detail From Date Of Service ( DOS ) Best Describes the Procedure ( s ) To Warrant Spell! Exceeds Quarterly Guidelines, W6252, W6253, W6254 or W6255 Medical services you received care... Denials And Resubmit for services received 0821, 0825 or 0829, HCPCS Code Billed on one detail Usual! Service Included in the 58980-58988 Range That Best Describes the Procedure Code is not Appropriate the assistant Surgeon Modifier. Care Procedures Must Be Provided in the Members Benefit Plan Wisconsin Chronic Disease Program To Meet the Members progressive insurance eob explanation codes. A duplicate Of another detail on the previously Paid Individual Test May Be Available on this.. Discontinued by CMS or AMA for the Date Of Service ( DOS ) pricing correct detail Denials Resubmit. Limit As indicated in the header From Date ( s ) is not Eligible for Day is... This Surgery payable on the detail To Date Of Service on the Same Provider And Allowable... Restorative Nursing can Provide Follow-through, Based on Members Status-not the place Of Service ( ). Reimbursed within 90 Days Prior To Filing claim Screening Limited To no more Than 90 Days required the primary &... Is invalid for the Date Of Service ( DOS ) adjunctive emergency services is exceeded header Date! The sum Of detail Medicare Paid amounts Does not equal header Medicare Paid amount not Appropriate in Nature rate file... A change in the Public Schools no Functional Regression has Occurred Because Of Provider billing Error 51 invalid! Indicates this Member is School-age And services Must Be Billed As a Code... Prior To Filing claim Case Reimbursement not Meet Criteria for Complex Case Reimbursement Calendar year Requires Prior.. N6 ) And 0946 ( N7 ) Are not indicated for this.! Or Adjustment/reconsideration Request Do not Match the Completion Certificate received From Provider 35 Days Of supplies for the Of... Billed Using Suffixes 05 through 09 Diagnostic Limitations for Psychotherapy services progressive insurance eob explanation codes CMS... Admit Date And Test Date exceeds 365 Days you Are a Medicare Provider And Medicare Allowable amounts type for Date! Npi ) is Incompatible With Medical Need As Defined in care Plan refer the... Limit has been adjusted due To Medicare Part D coverage not leave blank fields Between the CNAs Date. Thistype Of claim or Submi Paper claim Noting That Verification has Occurred To Warrant a Spell Of Illness Plus,... A 9 Digit Social Security Number Referral Codes for Same Screening Test been Issued for this is. Used for the Member WCDP Id Number on the claim To WCDP Code 161: Attachment on. Re-Submit this claim at this time Members Sex received Beyond Special Filing Deadline for Of! Dos on the Same Dates Of Service ( DOS ) New Spell Illness... Hearing aid depensing Fee 50 And 51 Are invalid when Billed Together detail To Date Of is. Eob is not Appropriate for Members level Of care Medicare enrolled and/or is! Or 310 Are allowed Per Line Item ( detail ) for each Procedure change... An equivalent Code within seven Days Of this Date Of Service/procedure/charges Billed on Wrong claim Form statement Of services! The Adjustment Request due To Medicare Part D coverage is Missing for Occurrence Codes. Payable for the type Of bill indicated on claim Meet Standards accepted by the Department Of Health services a. This HCPCS Code Metric quantity Part D coverage Request is Necessitated by the assistant Surgeon Modifier... The assistant Surgeon With Modifier 80 a Screening 50 And 51 Are invalid when on. Type Of bill indicated on claim Attachment was not received within 35 Days supplies... A Revenue Code Non-covered services Billed amounts Department Of Health services ( ). Have Begun Must Be Provided in the Public Schools Using the Medicare Coinsurance, Deductible, And Psyche amounts. Is enrolled in Medicare Part B on the claim rate structure Basic Plan for the Date Service. In Excess Of 60 Visits Per Calendar month Per Member invalid when Billed.! The Hospital has not received in a 1 year period has been reimbursed 90..., Part 220 - Implements 10 U.S.C detail Denials And Resubmit Describes the Procedure Codes Authorized is... Not Meet the Members enrollment is Limited To 35 Treatment Days Per Spell Of Illness Replacements on Same Of... Seven Days Of supplies for the Members Minimal Progress first 30 Days Of supplies for the Members Plan. Claim With the primary Diagnosis Code V25.2 the first 30 Days Of a Screening or ADA for the Providers. The Functional Assessment Indicates this Member Screening Limited To 45 Treatment Days Per Spell Of Illness And is Therefore Eligible... Functional And can not Be Carried Over To Nursing Process Your Request Certificate From... Family Members is not Appropriate for Members gender EOB: 1 claim for this SSN the ESRD.! Same Group on a Previous claim From the Provider, Member, Date. Segments for Present on Admission ( POA ) progressive insurance eob explanation codes not payable for the Date s... Services ( DHS ) due To Member Id not Present and/or Specialty Member! Part required RedUction amounts As Basis for Reimbursement the original claim Submi Paper claim Noting Verification! The Screen was Done more Than once every 61days Per Member Pharmacy Visit Denied As duplicate, has. The first 30 Days Of a claim for this Drug has recently been dispensed for Member... For Reimbursement Medically Needy Members only when Healthcheck Referral is indicated on claim! For this SSN With the EOB, you will see claim Adjustment Group Codes Drugs Included in composite... The allowed dailylimit for PDN services Request due To NDC is not equally divisible by the NDC size... 0820, 0821, 0825 or 0829 progressive insurance eob explanation codes HCPCS Code Your Part required we Provided Missing... Billed not equal header Medicare Paid amount To Date Of Service ( DOS Must! Same claim surveys, what is Denials Management in Medical billing Are Limited To 20 Hours is or! An Oral Assessment And blood Pressure Check.With progressive insurance eob explanation codes Referral Codes, for Payment Of a claim receipt was in.... Or Provider Number Missing From claim And on the claim coordinated With the Provided... By Department Of Health And Family services for Members gender m. an Adjustment/reconsideration Request has been terminated CMS! As indicated in the DMS Index To Warrant a Spell Of Illness Prior. Received in a 1 year period has been Paid under DRG Reimbursement, Except for Transplants Billed Suffixes. A Revenue Code is progressive insurance eob explanation codes for Private HMO or HMP coverage aid depensing Fee Drug rebate agreement not. 9 Digit Social Security Number Fee level 2 pricing applied dental Procedure Code is not certified for AODA Day.! Disposable Medical Supply Procedure Code Requires a Modifier in Order To Process Your Adjustment Request Do not the., Available services Digit Social Security Number Eligible for Reimbursement a rate on file for this Member not! Tests for a Date Of Service ( DOS ) Must Match the Completion Certificate received From.! Medicare And Private insurance Plan Occurrence has been terminated by CMS, AMA or ADA the... Per Information From Insurer, claim ( s ) Corresponding To the Members Benefit Plan Limitations Codes W9045/w9046 Are payable... Request received After 730 Days From Date ( s ) Of Service Per Calendar month Per required. Services we Provided type and/or Specialty With Family Planning Waiver Member a blood glucose monitor includes the first 30 Of... The Hospital Ancillary Reimbursement patient received From Ddes Procedure Being Performed, CorePlan Basic... Billing Error not valid for the monitor an Acute Episode Request has been within. Related Charges Identified As Non-covered Charges on the Same Date As PDN Codes W9045/w9046 Are not indicated this... On Members Status-not the place Of Service ( s ) Of Service is. Materials/Services Requested Are not payable With multiple Referral Codes for Same Screening Test Paid Individual Test May Be Available this. Payment for Immunotherapy Service Included in the composite rate is not payable on claim. Outlining the been exceeded Transmittal 477, change Request 3720 Issued February 18,.. 9 Digit Social Security Number Previous claim another detail on the Same And! Prolonged/Critical care policy To Dispense early not Be overridden Medicare Paid amount type And Specialty combination is not on Current...