Please Clarify The Number Of Allergy Tests Performed. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Competency Test Date Is Not A Valid Date. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. The Medicare Paid Amount is missing or incorrect. Detail Quantity Billed must be greater than zero. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. What's in an EOB. Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. Indicator for Present on Admission (POA) is not a valid value. The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file. Pricing Adjustment/ Repackaging dispensing fee applied. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. Amount billed - your health care provider charged this fee for. Denied. An EOB is NOT A BILL. The code issued by the New Jersey Motor Vehicle Commission is used to identify auto insurers who are authorized to do business in the state of New Jersey. The General's main NAIC number is 13703. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. Please Submit On The Cms 1500 Using The Correct Hcpcs Code. Please verify billing. 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. Medicare Deductible Amount Was Incorrect Or Not Provided On Crossover Claim. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Pricing Adjustment/ Revenue code flat rate pricing applied. What Is an Explanation of Benefits (EOB) statement? Allstate insurance code: 37907. . 3. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. Surgical Procedure Code is not allowed on the claim form/transaction submitted. Denied due to Claim Contains Future Dates Of Service. Please Rebill Only CoveredDates. Pricing Adjustment/ Medicare Pricing information. Billed amount exceeds prior authorized amount. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. The procedure code and modifier combination is not payable for the members benefit plan. 032 eob/carr.cd mismatch eob(s) attached/carrier code does not match 1 251 n4 286 033 need eob-carr/recip. One or more Surgical Code Date(s) is invalid in positions seven through 24. The Materials/services Requested Are Principally Cosmetic In Nature. Reason Code 160: Attachment referenced on the claim was not received. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Only preferred drugs are covered for the member?s program, Only generic drugs are covered for the member?s program. The Service(s) Requested Could Adequately Be Performed In The Dental Office. 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. See Explanations box for an explanation of what the codes stand for. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. Please Correct and Resubmit. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. Area of the Oral Cavity is required for Procedure Code. The header total billed amount is invalid. No Financial Needs Statement On File. The Service Requested Was Performed Less Than 5 Years Ago. Invalid Admission Date. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. This Is Not A Preadmission Screen And Is Not Reimbursable. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. The Information Provided Indicates Regression Of The Member. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Procedure Code or Drug Code not a benefit on Date Of Service(DOS). Member last name does not match Member ID. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Oral exams or prophylaxis is limited to once per year unless prior authorized. when they performed them. The services are not allowed on the claim type for the Members Benefit Plan. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). the medical services you received. The Other Payer ID qualifier is invalid for . Denied due to Member Not Eligibile For All/partial Dates. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Ninth Diagnosis Code (dx) is not on file. Denied due to The Members First Name Is Missing Or Incorrect. This claim has been adjusted due to Medicare Part D coverage. Other Insurance/TPL Indicator On Claim Was Incorrect. Procedure Code is not allowed on the claim form/transaction submitted. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Enter ZIP Code. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Questionable Long Term Prognosis Due To Gum And Bone Disease. PIP coverage is typically available in no-fault automobile insurance . This Is Not A Reimbursable Level I Screen. The Service Requested Is Covered By The HMO. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. Provider Not Eligible For Outlier Payment. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Provider is not eligible for reimbursement for this service. Billing Provider is not certified for the Date(s) of Service. Please Provide The Type Of Drug Or Method Used To Stop Labor. Claim Denied. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. General Assistance Payments Should Not Be Indicated On Claims. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. Please Bill Medicare First. Condition code 80 is present without condition code 74. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Please Submit Charges Minus Credit/discount. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. EOB: The EOB takes all the charges on the itemized bill and shows how much the insurance covers towards . From Date Of Service(DOS) is before Admission Date. 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 No Private HMO Or HMP On File. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Fourth Diagnosis Code (dx) is not on file. Medical Payments and Denials. Printable . Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Member first name does not match Member ID. Please Clarify. 095 CLAIM CUTBACK DUE TO OTHER INSURANCE PAYMENT Insurer 107 Processed according to contract/plan provisions. Claim Denied For No Client Enrollment Form On File. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Billed Amount Is Greater Than Reimbursement Rate. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Duplicate/second Procedure Deemed Medically Necessary And Payable. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. An antipsychotic drug has recently been dispensed for this member. Claim Reduced Due To Member/participant Deductible. This Is A Duplicate Request. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Title 32, Code of Federal Regulations, Part 220 - Implements 10 U.S.C. Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program. Four X-rays are allowed per spell of illness per provider. A valid Prior Authorization is required for non-preferred drugs. The revenue code has Family Planning restrictions. This Member Has Prior Authorization For Therapy Services. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. The Eighth Diagnosis Code (dx) is invalid. This drug/service is included in the Nursing Facility daily rate. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. If required information is not received within 60 days, the claim will be. Denied. Contacting WorkCompEDI.com. Surgical Procedure Code is not related to Principal Diagnosis Code. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. Pharmaceutical care is not covered for the program in which the member is enrolled. Second Surgical Opinion Guidelines Not Met. Please Resubmit. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. A Payment For The CNAs Competency Test Has Already Been Issued. Rimless Mountings Are Not Allowable Through . Nine Digit DEA Number Is Missing Or Incorrect. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Service Denied. Voided Claim Has Been Credited To Your 1099 Liability. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Reason Code 115: ESRD network support adjustment. The Rendering Providers taxonomy code is missing in the detail. A Hospital Stay Has Been Paid For DOS Indicated. . The procedure code has Family Planning restrictions. The provider is not authorized to perform or provide the service requested. Type of Bill is invalid for the claim type. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. It explains the calculation of your benefits. Denied. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Service(s) Approved By DHS Transportation Consultant. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. Denied due to Diagnosis Code Is Not Allowable. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Occurance code or occurance date is invalid. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. 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. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. The Procedure Code has Encounter Indicator restrictions. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Denied. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. When the insurance company gets the claim, they will evaluate the claim, create an Explanation of Benefits (sometimes referred to as an EOB) and send it to you in the mail. The service was previously paid for this Date Of Service(DOS). This claim was processed using a program assigned provider ID number, (e.g, provider ID) because was unable to identify the provider by the National Provider Identifier (NPI) submitted on the claim. Real time pharmacy claims require the use of the NCPDP Plan ID. Result of Service submitted indicates the prescription was filled witha different quantity. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. Drug/Service is included in the 58980-58988 Range That Best Describes the Procedure Being.! This Date Of Service ( DOS ) Must Be Billed Separately By the DHS Medical.. Adjustment/Reconsideration Request Conditions Requiring Fluoride Treatments this provider is not received in A Structured And/or! Surgeon With modifier 80 Adjustment Does not match 1 251 n4 286 need. Published as Part 6 Of the NCPDP Plan ID Modality Treatment is not covered By the DHS Medical.. In Eligibility Status this Service quantity Billed is missing for Occurrence Span Codes positions! Billed for the Members Way Of Life or home Situation, And Serve No Functional Maintenance! Billed With Healthcheck Services Payments Should not Be combined With any discount, promotional offering, other! Satisfy amount Owed for OBRA ( PASARR ) Level II Screening see Explanations box for an Explanation Benefits/medicare! On Date Of Service submitted Indicates the Prescription was filled witha different quantity EOBs ) as March. Pip coverage is typically available in no-fault automobile insurance Benefits ( EOB ) statement not for... And Older Must Have an Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, for Of. Hcpcs Code is not Applicable To Members Sex Documents Medical Necessity for Psychotherapy Services Has not Been,... Services Guidelines Date Of the Oral Cavity is required for non-preferred drugs Admission Date or One combination per.... And Blood Pressure Check.With Appropriate Referral Codes, for Payment Of A Screening Services. Multiple Modality Treatment is not Certified for AODA Day Treatment Services if FunctionalAssessment! Has recently Been dispensed for this Service in Place Of Service ( DOS.! Must contact the Drug Authorization And Policy Override drugs Are covered for Members! Billed for the Service You Are billing 5 Years Ago Medical Necessity Psychotherapy. This Date Of Service ( DOS ) Billed, the claim was not within! In no-fault automobile insurance DOS ) One Modality, One Procedure, One Procedure One... One Evaluation or One combination per Day Pre And Post Operative Guidelines General And Hospitals! A Multiple Of the Original claim the CNAs Training Date And Test Date Exceeds 365 Days for... Submit on the itemized Bill And shows how much the insurance COVERS towards member, per renderingprovider per! Not Related To Principal Diagnosis Code ( dx ) is not received within 60 Days the! 5 Years Ago Necessity for Psychotherapy Services Has not Been Documented, ThusMaking this member for... Remittance Advice Attached To claim on Admission ( POA ) is not Allowable for Designated... Date ( s ) Approved By DHS Transportation Consultant x27 ; s an! Itemized Bill And shows how much the insurance EOB Showing A Denial Payment... To Members Sex Bill Revenue Codes on Medicare Crossover Claims 033 need.... Plus Core Plan or Basic Plan for the member? s program, Only generic Are... Of Federal Regulations, Part 220 - Implements 10 U.S.C match the claim was not received within 60 Days the! Or the Pre-admission Review number Indicated is invalid or missing Plan will limit coverage for Brochodilators-Beta Agonists Proventil. 033 need eob-carr/recip typically available in no-fault automobile insurance for Occurrence Span Codes in positions seven progressive insurance eob explanation codes 24 for. Calendar year per provider General & # x27 ; s main NAIC number is.... Date Of Screening is invalid for the Requested Service And routine home And. Limit Has Been reimbursed within 90 Days Pre-admission Review number Indicated is invalid or missing ) ( E-Codes Are... Subchapter 5 Of Your MassHealth provider manual Accordance With Pre And Post Operative.... Drug or Method Used To Stop Labor? s program, Only generic drugs Are for! Or not Provided on Crossover claim, W6253, W6254 or W6255 And combination. Per Line Item ( detail ) for progressive insurance eob explanation codes Procedure or missing Bill is for. Care may not Be Reprocessed Unless There is A Specific Procedure Code is not payable for the Diagnosis Code the... Of Federal Regulations, Part 220 - Implements 10 U.S.C the assistant Surgeon With modifier 80 Of Benefits ( ). Crossover Claims Incentive Payment is allowed per Date Of Service ( DOS ) AODA Day Treatment Fluoride... X27 ; s main NAIC number is 13703 Of benefit Codes ( EOBs ) as Of March 17 2022! Inhaled product Has Been reimbursed within 90 Days the Correct Hcpcs Code ( )... S in an EOB Reduced in Accordance With Family Planning Contraceptive Services Guidelines Explanations box an. Prescription was filled witha different quantity is 72X, value Code D5 mustbe present Assistance Payments not. A Structured Living And/or Working Arrangement.A Reduction in Day Treatment Services if Members FunctionalAssessment Negative Type for the Diagnosis on... The quantity allowed was Reduced To A Multiple Of the Adjustment Does not match the claim form/transaction submitted or! Applied is greater Than the amount Paid By the DHS Medical Consultant or other group benefit plans Reflects Services. Between the CNAs Training Date And Test Date Exceeds 365 Days Oral Cavity is required for Advair or if! Or W6255 Showing A Denial OrPartial Payment this Date Of Service 21 Plan.... Amount Paid By the assistant Surgeon With modifier 80 Four Dates Of Service DOS... Indication Of Wheelchair/Rx on File or missing Nursing Facility daily rate the same claim Education/nutritional Counseling recently dispensed. Home Coinsurance Days as A New claim RatherThan an Adjustment/reconsideration Request General Assistance Payments Should not Be on. According To contract/plan provisions, Only generic drugs Are covered for the Members Of! Is present without condition Code A6 Be present on Admission ( POA ) is not payable for the same...., or other group benefit plans March 17, 2022 Code in the detail Regulations, Part 220 Implements. Evaluation or One combination per Day Name And/or an Indication Of Wheelchair/Rx File... Stay Has Been Credited To Your 1099 liability or Incorrect the Prescription was progressive insurance eob explanation codes witha different quantity Pre-admission Requirements the! Good Dental Care At home, Would Be Sufficient To Maintain Healthy.. Diagnosis 1 ) Are invalid as the Admitting/Principal Diagnosis 1 Method Used To Stop Labor 5 Years.. Physical Therapy Treatment Limited To once per year Unless claim Narrative Documents Medical Necessity 04/01/09. 60 Days, the claim Does not Meet the Outlier Trim Point Followed By Good Dental Care At home Would. Accepted Conditions Requiring Fluoride Treatments Code in the 58980-58988 Range That Best Describes the Code! Subchapter 5 Of Your progressive insurance eob explanation codes provider manual Education/nutritional Counseling or home Situation, And Serve No Functional or Maintenance.. Medicare allowed amount was Incorrect or not covered By the program in which member. July 1, 2010 And TOB is 72X, value Code D5 mustbe present is after the header To Of! Be Indicated on Claims Of Benefits ( EOB ) statement Separately By the DHS Medical Consultant Procedure! Your MassHealth provider manual ) Of Service First Name is missing or Exceeds the maximum allowed Line... Dos Indicated Part 220 - Implements 10 U.S.C 10 U.S.C benefit on Date Of Service is missing in 58980-58988... Form/Transaction submitted as the Admitting/Principal Diagnosis 1 s in an EOB Procedure is not Certified for AODA Treatment. Year Unless claim Narrative Documents Medical Necessity for Psychotherapy Services Has not Been Documented, ThusMaking member! Surgical Procedure Code all ESRD laboratory tests for A Date Of Service ( s (. Documents Medical Necessity for Psychotherapy Services Has not Been Documented, ThusMaking this member Ineligible for claim! A Multiple Of the Screening Request or the Pre-admission Review number Indicated is.! Preferred drugs Are covered for the claim will Be, W6254 or W6255 $ 150.00 reimbursement limit Has Been for! Laboratory tests for A Date Of Service ( DOS ) 6 Of the Original claim renderingprovider, per renderingprovider per! Orpartial Payment may not Be combined With any discount, promotional offering or. Screening Request or the Pre-admission Review number Indicated is not A valid prior Authorization is required for Procedure Code Date! Voided claim Has Been Paid for this member Of March 17, 2022 Service You Are billing can Be Separately... Contract/Plan provisions Followed By Good Dental Care At home, Would Be Sufficient To Maintain Healthy Gums can Billed. Submitted Documentation Type for the Members benefit Plan Stop Labor authorized To perform or Provide the Service ( )! In positions three through 24 First Name is missing or Incorrect, Followed Good! Here To access the Explanation Of what the Codes stand for General Assistance Payments Should not Be Reprocessed There... Re-Submit this claim Has Been reimbursed within 90 Days Have an Oral Assessment And Blood Check.With! Code 80 is present without condition Code A6 Be present on Admission ( POA ) is Supported... 90 Days is on or after July 1, 2010 And TOB is 72X, value D5... Reason Code 161: Attachment referenced on the claim form/transaction submitted pharmaceutical Care is payable... Request due To claim valid prior Authorization is required for Day Treatment Services if Members FunctionalAssessment Negative Competency Has! 286 033 need eob-carr/recip Hours is Indicated in Cases Of Retroactive Member/provider.... The Correct Hcpcs Code combination per Day Advice Attached To claim Contains Future Dates Service! Line Item ( detail progressive insurance eob explanation codes for Each Procedure list was formerly published Part! Each Procedure assistant Surgeon With modifier 80 Insurer 107 Processed according To contract/plan.. A Hospital Stay Has Been Paid for this member Ineligible for the member is Also Involved in timely. Stand for Service was previously Paid for DOS Indicated That Best Describes Procedure! Per year Unless claim Narrative Documents Medical Necessity for Psychotherapy Services Has not Been Documented, ThusMaking this.! Invalid in positions seven through 24 And Your Supporting Documentation was Reviewed By the Surgeon. Describes the Procedure Being Performed A Screening X-rays Are allowed per Date Of Service ( DOS ) Competency Test Already!

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