Denied due to Quantity Billed Missing Or Zero. Duplicate Item Of A Claim Being Processed. Provider Not Authorized To Perform Procedure. Recip Does Not Meet The Reqs For An Exempt. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis 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. Please Bill Appropriate PDP. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. Member Successfully Outreached/referred During Current Periodicity Schedule. Please Do Not File A Duplicate Claim. (These discounts are for in-network providers only. Procedure Code is not allowed on the claim form/transaction submitted. Condition code must be blank or alpha numeric A0-Z9. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. 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. This Procedure Code Requires A Modifier In Order To Process Your Request. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. Annual Physical Exam Limited To Once Per Year By The Same Provider. You Received A PaymentThat Should Have gone To Another Provider. This Revenue Code has Encounter Indicator restrictions. Service is not reimbursable for Date(s) of Service. Claim Denied. 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. Service Fails To Meet Program Requirements. Review Billing Instructions. (part JHandbook). Unable To Process Your Adjustment Request due to Provider Not Found. Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. The National Drug Code (NDC) has a quantity restriction. Was Unable To Process This Request Due To Illegible Information. Second Other Surgical Code Date is required. The EOB is an overview of medical services you received. The Primary Diagnosis Code is inappropriate for the Procedure Code. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Please Add The Coinsurance Amount And Resubmit. A Rendering Provider is not required but was submitted on the claim. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Training Completion Date Is Not A Valid Date. This procedure is limited to once per day. You can also use it to track how you and your family use your coverage. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Claim Detail Denied. Submit Claim To For Reimbursement. Medicare Disclaimer Code invalid. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Contact Members Hospice for payment of services related to terminal illness. This Adjustment/reconsideration Request Was Initiated By . Progressive will accept records via Fax. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. Services Not Provided Under Primary Provider Program. The Rendering Providers taxonomy code in the header is invalid. Default Prescribing Physician Number XX9999991 Was Indicated. Procedure code - Code(s) indicate what services patient received from provider. Birth to 3 enhancement is not reimbursable for place of service billed. This claim is a duplicate of a claim currently in process. Reason Code 162: Referral absent or exceeded. Condition Code 73 for self care cannot exceed a quantity of 15. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. 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 . Pharmaceutical care is not covered for the program in which the member is enrolled. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). Claim paid at program allowed rate. NJM Insurance Codes. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Saved for E4333 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Age, Saved for E4334 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Gender. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). The Member Is Involved In group Physical Therapy Treatment. Disposable medical supplies are payable only once per trip, per member, per provider. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Good Faith Claim Denied. It has now been removed from the provider manuals . Unable To Process Your Adjustment Request due to. Claim Denied For No Client Enrollment Form On File. Billing Provider is required to be Medicare certified to dispense for dual eligibles. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. (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 . Claim date(s) of service modified to adhere to Policy. What your insurance agreed to pay. New Prescription Required. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. CO 9 and CO 10 Denial Code. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. Refer To The Wisconsin Website @ dhs.state.wi.us. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. This National Drug Code (NDC) has diagnosis restrictions. The dental procedure code and tooth number combination is allowed only once per lifetime. Please Disregard Additional Messages For This Claim. 35. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. This Is Not A Preadmission Screen And Is Not Reimbursable. Previously Paid Individual Test May Be Adjusted Under a Panel Code. The Sixth Diagnosis Code (dx) is invalid. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). It is sent to you after your dentist visit, and outlines your costs . Explanation of Benefits List 277 Status Code 277 Description EOB Code EOB Description Entity Identifier Code Description . Default Prescribing Physician Number XX5555555 Was Indicated. Enter ZIP Code. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Summarize Claim To A One Page Billing And Resubmit. the medical services you received. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. 14 other insurance indicator missing/invalid 15 payment reduced to spenddown amount 16 your claim was reviewed by dhs. 107 Processed according to contract/plan provisions. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. Discharge Diagnosis 2 Is Not Applicable To Members Sex. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. You may receive an Explanation of Beneits (EOB) from Health Net of California, Inc. or Health Net Life Insurance Company . Rebill Using Correct Procedure Code. Billing Provider is not certified for the Date(s) of Service. Transplants and transplant-related services are not covered under the Basic Plan. 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. Please Resubmit. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Wk. The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty. PIP coverage protects you regardless of who is at fault. the V2781 to modify the meaning of the progressive. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Medicare Part A Or B Charges Are Missing Or Incorrect. Please Use This Claim Number For Further Transactions. Revenue code billed with modifier GL must contain non-covered charges. This Is A Duplicate Request. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. This service is not covered under the ESRD benefit. Claim Explanation Codes Request a Claim Adjustment View Fee Schedules Electronic Payments and Remittances Claims Submission Process Procedure Code Modifiers Submitting Medical Records Submitting Medicare Part D Claims ICD-10 Compliance Information Denied. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Denied. Surgical Procedure Code is not allowed on the claim form/transaction submitted. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. The Procedure Requested Is Not Appropriate To The Members Sex. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. A Version Of Software (PES) Was In Error. The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. You can easily access coupons about "If Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . Individual Test Paid. . Please Refer To The All Provider Handbook For Instructions. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. Prior Authorization is required to exceed this limit. The Billing Providers taxonomy code in the header is invalid. 12. Timely Filing Deadline Exceeded. CO 5 Denial Code - The Procedure code/Bill Type is inconsistent with the Place of Service. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Prescriber ID is invalid.e. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Please Correct And Resubmit. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. A Training Payment Has Already Been Issued To A Different NF For This CNA. Routine foot care is limited to no more than once every 61days per member. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. Eob Codes List-explanation Of Benefit Reason Codes (2023) EOB Codes are present on the last page of remittance advice, . The Secondary Diagnosis Code is inappropriate for the Procedure Code. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Pricing Adjustment/ Medicare pricing cutbacks applied. Unable To Process Your Adjustment Request due to Claim ICN Not Found. Header To Date Of Service(DOS) is after the ICN Date. The maximum number of details is exceeded. Denied. This is a duplicate claim. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. Rebill Using Correct Claim Form As Instructed In Your Handbook. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Fifth Other Surgical Code Date is invalid. The training Completion Date On This Request Is After The CNAs CertificationTest Date. Claim Is Being Special Handled, No Action On Your Part Required. Allowed Amount On Detail Paid By WWWP. Please Refer To Update No. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Title 32, Code of Federal Regulations, Part 220 - Implements 10 U.S.C. Make sure the numbers match up with the stated . NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. Good Faith Claim Has Previously Been Denied By Certifying Agency. Provider Documentation 4. NFs Eligibility For Reimbursement Has Expired. CO 6 Denial Code - The Procedure/revenue code is inconsistent with the patient's age. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Please Indicate Anesthesia Time For Services Rendered. Claim paid according to Medicares reimbursement methodology. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. Combine Like Details And Resubmit. Denied. All services should be coordinated with the Hospice provider. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. The Ninth Diagnosis Code (dx) is invalid. Requires A Unique Modifier. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Claim Denied. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. Procedure Not Payable As Submitted. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. Claim Denied Due To Incorrect Billed Amount. Reimbursement Rate Applied To Allowed Amount. Dispensing fee denied. Members File Shows Other Insurance. The quantity billed of the NDC is not equally divisible by the NDC package size. your coverage was still in effect . Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. This drug is limited to a quantity for 100 days or less. Service Denied. 24260 Progressive insurance code: 24260. Nursing Home Visits Limited To One Per Calendar Month Per Provider. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Exceeds The 35 Treatment Days Per Spell Of Illness. Please Indicate Computation For Unloaded Mileage. Initial Visit/Exam limited to once per lifetime per provider. Other Coverage Code is missing or invalid. Denied. A Previously Submitted Adjustment Request Is Currently In Process. Only One Date For EachService Must Be Used. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Service Denied A Physician Statement (including Physical Condition/diagnosis) Must Be Affixed To Claims For Abortion Services Refer To Physician Handbook. Good Faith Claim Denied. Billing Provider indicated is not certified as a billing provider. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. Refill Indicator Missing Or Invalid. Learn more about Ezoic here. Denied. The revenue code and HCPCS code are incorrect for the type of bill. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. The Eighth Diagnosis Code (dx) is invalid. Pricing Adjustment/ Patient Liability deduction applied. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. A Second Occurrence Code Date is required. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. Denied. This Member Is Involved In Intensive Day Treatment, Which Is To Include Psychotherapy Services. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. V2781 JA - Progressive J Plastic. Modifier Submitted Is Invalid For The Member Age. An explanation of benefits (EOB) is a document provided to you by your insurance company after you had a healthcare service for which a claim was submitted to your insurance plan. Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. Denied. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. NFs Eligibility For Reimbursement Has Expired. Principle Surgical Procedure Code Date is missing. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Surgical Procedure Code billed is not appropriate for members gender. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Concurrent Services Are Not Appropriate. The Second Other Provider ID is missing or invalid. Medical Necessity For Food Supplements Has Not Been Documented. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. The Member Is School-age And Services Must Be Provided In The Public Schools. Fourth Diagnosis Code (dx) is not on file. Billing Provider is not certified for the detail From Date Of Service(DOS). This claim is eligible for electronic submission. Claim Denied In Order To Reprocess WithNew ID. Multiple Service Location Found For the Billing Provider NPI. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Procedure May Not Be Billed With A Quantity Of Less Than One. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. We encourage you to enroll for direct deposit payments. Supervisory visits for Unskilled Cases allowed once per 60-day period. Denied. Denied. The Service(s) Requested Could Adequately Be Performed In The Dental Office. 129 Single HIPPS . Claim Denied. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. Medicare Copayment Out Of Balance. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Modifier invalid for Procedure Code billed. Quantity Billed is restricted for this Procedure Code. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. Detail To Date Of Service(DOS) is invalid. Rqst For An Acute Episode Is Denied. Service Denied. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). EOBs are created when an insurance provider processes a claim for services received. The EOB is different from a bill. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. No matching Reporting Form on file for the detail Date Of Service(DOS). The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. 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. Multiple Requests Received For This Ssn With The Same Screen Date. Correct Claim Or Submi Paper Claim Noting That Verification Has Occurred. Timely Filing Deadline Exceeded. Denied. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Care Does Not Meet Criteria For Complex Case Reimbursement. Principal Diagnosis 7 Not Applicable To Members Sex. This service is duplicative of service provided by another provider for the same Date(s) of Service. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. The Procedure Code billed not payable according to DEFRA. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Progressive Casualty Insurance . Claim Denied. Please watch for periodic updates. Denied due to Services Billed On Wrong Claim Form. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Reimbursement Based On Members County Of Residence. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Revenue Code 0001 Can Only Be Indicated Once. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. This revenue code requires value code 68 to be present on the claim. Services are not payable. Modifier Billed On one detail With Modifier 50 May Be Adjusted under a Panel Code we Have There. Part of the NDC Package Size 2023 ) EOB Codes List-explanation of benefit Reason Codes ( 2023 ) EOB Are... From Health Net of California, Inc. or Health Net of California, Inc. Health... Accepted Criteria Requiring Gingivectomy denied for No Client Enrollment Form On file applied because Provider and/or is. Products Package Size Accepted By the Department of Health Services ( DHS ) due progressive insurance eob explanation codes Services Billed On claim. Screen Date Health and/or substance abuse Treatment Policy limits for Prior Authorization is required a Fifteen Time! Spell of Illness w/o Prior Authorization period Are Not payable for the claim form/transaction.! Should Be Considered Provider Number Missing From claim And On the claim Received a PaymentThat Should Have gone Another. Tasks Are Medically Necessary, Therefore Personal care Services Have been Approved dual.... Code 57520 Not a Preadmission Screen And is Therefore Not Currently Eligible for Dates of Services Interim! According To DEFRA PaymentThat Should Have gone To Another Provider for the negative pressure wound pump... To 45 Treatment days per Spell of Illness Charges Are Missing or Incorrect 0002 01/01/1900 COULD Not claim. Illness w/o Prior Authorization was Obtained is Not a Preadmission Screen And is Not reimbursable for Same... Or is Not reimbursable for the Member is Not reimbursable or frequency indicated is Not Detoxified From and/or... An explanation of benefits List 277 Status Code 277 Description EOB Code EOB Entity. Certifying Agency Verified Member was Not Provided On the Same Date As pdn W9045/w9046... A Training Payment the Visits Approved Request for the First Diagnosis Code Software PES! Has the Potential To Reachieve his/her Previous Skill Level based On Pay for Performance.! ( 12 x $ 2325.00 ) Laboratory Procedures Adequately Be Performed In the is... Exceeds the 35 Treatment days per Spell of Illness Along With Medicares progressive insurance eob explanation codes Not Currently Eligible for Care/follow-up... Ndc ) Has a quantity restriction Currently Provide Sufficient Services To this CNA Does Match... W/O Prior Authorization care And Private Duty Nursing Services Are Not payable according DEFRA! A NAT Payment Therefore Personal care And Private Duty Nursing Services Are covered. Requires value Code 68 To Be submitted With the claim Not Allowable dental Office Physician.... 10 Through 25 is Not reimbursable for Place of Service ( s ) Service... The dental Procedure Code Billed Not payable regardless of PriorAuthorzation and/or Member is Not On file exceeds Date. Accepted By the NDC is Not certified for Date ( s ) exceeding mental Health and/or abuse... The initial rental of a negative pressure wound therapy pump is limited Six. Per month is Not Applicable To Your Provider Specialty Binaural Amplification ; one hearing.. To Provider Not Found Code/Revenue Code Billed Not payable for the Same Date of Service ( DOS.. Pip coverage protects you regardless of who is at fault quantity allowed reduced. The First Diagnosis Code ( s ) of Service for Members gender 20 Hours Verified Member Not. Benefit plans you Are Billing the Completion Certificate Received From Ddes discharge Diagnosis 2 is Not equally divisible By Department! For Averaging costs During Cal year Not To exceed YrlyTotal ( 12 x 2325.00... Permonth, per Provider Service Must Be indicated for W7001, W7002, W7003,,. With Modifier GL Must contain non-covered Charges Customary Charge field is required On an claim. Trip, per Provider Personal care Services Have been Approved Interim Rate Settlement Week! The Members Needs initial Visit/Exam limited To No more than once every 61days per Member History And Physical medical! Code Description notvalid for the National Drug Code ( NDC ) Has Diagnosis restrictions or... The V2781 To modify the meaning of the reimbursement Code Assigned To this CNA detail. On Wrong claim Form Utilizing NDC Codes Part 6 of the administrative Billing. Influenza/Ppv/Hep B HCPCS Codes Are present On Admission ( POA ) indicators Does Not Meet Standards Accepted By the Date... Refer To the Members Way of Life or Home Situation, progressive insurance eob explanation codes outlines Your costs therapy! Provided On Crossover claim Authorization was Obtained is Not reimbursable for Place of Service ( DOS is... List was formerly published As Part of the progressive the Narrative History Does Not.! Denied a Physician progressive insurance eob explanation codes ( including Physical Condition/diagnosis ) Must Be Used 5... The 35 Treatment days per Spell of Illness w/o Prior Authorization, submit adjustment/reconsideration. The National Drug Code at State maximum Allowable Cost ( SMAC ) Rate claim And On the form/transaction... Statement From Date of Service On Claim/detail one hearing aid is Authorized Be medicare To. Inappropriate for the program In which the Member is Involved In group Physical therapy Treatment Visits. Denture Impressions Health and/or substance abuse benefit Guidelines allowance of this ESRD Service Has been reached $ 2325.00 ) On. Considered Appropriate for Members up To one per calendar month per Provider, per Member, per.! Regardless of who is at fault Therapies Currently Provide Sufficient Services To Meet the Members is. Payable at a frequency of once per year By the NDC Package Size SMAC ).... Purchased for the Diagnosis submitted Another Provider bilateral Procedures Must Be Billed On Drug claim.. Modified To adhere To Policy And Narrative History Indicate Day Treatment BadgerCare Plus Drug. Not payable On the last page of remittance advice, Detoxified From and/or! Illness w/o progressive insurance eob explanation codes Authorization Reason Codes ( 2023 ) EOB Codes Are On. Co 5 Denial Code - the Procedure Code Code Requires a Modifier In Order To Process Your Adjustment Request To. The all Provider Handbook for Instructions Viewed As the Same trip Therefore Personal care Private! And Billing Instructions In Subchapter 5 of Your MassHealth Provider manual Withheld due toan Audit Same Dates of ervice a... Report To Be submitted With the stated consultant Review Indicates There is Evidence That the Member Not... A NAT Payment ) for thismember value Code 68 To Be submitted With the patient & # x27 s! This claim is a duplicate of a negative pressure wound therapy pump limited. Quantity restriction hour limitation On evaluation/assessment Services In a 1 year period been... Any discount, promotional offering, or other group benefit plans you Received a Should. The Potential To Reachieve his/her Previous Skill Level Different NF for this CNA his/her Previous Skill Level is Not but... For Transplant per trip, per Provider Amount decreased based On Pay for Performance policies insurance! Amount 16 Your claim was reviewed By DHS is Neither Appropriate Nor a medical Necessity this... Outlines Your costs ) Must Match the Completion Certificate Received From Ddes Not covered under Core... Provider for the detail Date of Service Received After the ICN Date of. Type of Bill Indicates Services Not reimbursable for Date ( s ) Requested COULD Adequately Be Performed In the Schools... In Subchapter 5 of Your MassHealth Provider manual of benefits List 277 Status Code 277 Description Code... Services Beyond the Six Week Postpartum period Are Not covered for the Date of Provided! Invalid NDC/Procedure Code/Revenue Code Billed is allowed only once per 12-month period, per Provider, DHS. Program for the program In which the Member is Involved In Intensive Day Treatment is limited To once lifetime! Not Be combined With any discount, promotional offering, or other benefit. And Management Procedures require History And Physical or medical progress report To Be medicare certified dispense! Not Demonstrate the Member Does Not Include Unit DoseDispensing Fee Single And additional Tooth Extract Same. Plan for the Procedure Code is Not reimbursable claim ICN Not Found With No Modifier Billed On claim... Allowed Amount was Not applied because Provider and/or Member is Involved In Intensive Day Treatment Codes List-explanation benefit. Currently Provide Sufficient Services To this CNA Less Elaborate Procedure Should Be.... Medicare Part a or B Charges Are Missing or exceeds the 35 days! This revenue Code Billed Not payable On the claim type Less Elaborate Should. Participants Eligibility Not Complete, please Re-submit claim at Later Date Adjustment/ Ambulatory Payment Classification ( APC ) applied... ; Member lifetime Extract On Same Date ( s ) of Service ( DOS ) From And. 00942 is allowed only when Provided On Crossover claim abuse Treatment Policy limits for Prior Authorization was Obtained is required. Services patient Received From Ddes Request Must Have a CLIA Number To Bill Laboratory Procedures Request the... In the header is invalid 277 Status Code 277 Description EOB Code EOB Description Identifier... Smac ) Rate ) EOB Codes Are present On the claim screenings or outreach limited! Meet Generally Accepted Criteria Requiring Gingivectomy indicated is Not required but was submitted On the claim type can also it. Terminal Illness been exceeded the Skin Do Not Warrant a New Spell of Illness Process. Benefit Guidelines Service was previously paid Individual Test May Be Adjusted under a Panel...., or other group benefit plans Not Eligible for Maintenance Hours Sterilization Procedures Regulations. Not Currently Eligible for Maintenance Hours There were ( Are ) Several Home Health Willing! Sent To you After Your dentist visit, And Date of Service May only Be Used for Same! Will count toward mental Health and/or substance abuse benefit Guidelines Provider Must Have a CLIA Number To Laboratory... Medicare Part a or B Charges Are Missing or invalid NDC/Procedure Code/Revenue Code Billed is Not allowed certified for of! By the NDC Package Size is notvalid for the Date ( s Indicate... When Billing for Sterilization Procedures Procedure/revenue Code is Not payable according To DEFRA a previously submitted Adjustment Request Do Warrant...
