RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Denied. Pricing Adjustment/ Level of effort dispensing fee applied. Limited to once per quadrant per day. Explanation of Benefits (EOB) - A written explanation from your insurance . Denied due to Detail Billed Amount Missing Or Zero. The NAIC code is found on your . The Non-contracted Frame Is Not Medically Justified. A Payment For The CNAs Competency Test Has Already Been Issued. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. Please Clarify. PLEASE RESUBMIT CLAIM LATER. Prior Authorization Number Changed To Permit Appropriate Claims Processing. Denied. Oral exams or prophylaxis is limited to once per year unless prior authorized. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. Detail To Date Of Service(DOS) is required. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Request Denied. Payment Recouped. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Denied/recouped. All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. The Service Billed Does Not Match The Prior Authorized Service. The procedure code has Family Planning restrictions. Claim Detail Denied Due To Required Information Missing On The Claim. (part JHandbook). Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Billed Amount is not equally divisible by the number of Dates of Service on the detail. One or more Condition Code(s) is invalid in positions eight through 24. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Denied. An Explanation of Benefits, often referred to as an EOB, is a document that describes what costs a health insurance plan will cover for incurred healthcare and related expenses. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Denied. Billing Provider indicated is not certified as a billing provider. Result of Service code is invalid. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. The National Drug Code (NDC) has a quantity restriction. You can easily access coupons about "Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. Procedure Code is restricted by member age. Glass lens enhancement code is not allowed with a non-glass lens enhancement code . Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Traditional dispensing fee may be allowed. Prescription Date is after Dispense Date Of Service(DOS). AAA insurance code: 71854. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. Benefit Payment Determined By DHS Medical Consultant Review. Members age does not fall within the approved age range. Remark Code Description: additional explanation of the Remark or Discount Code will appear in this section. Resubmit charges for covered service(s) denied by Medicare on a claim. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Member Expired Prior To Date Of Service(DOS) On Claim. Denied. Paid In Accordance With Dental Policy Guide Determined By DHS. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Correct And Resubmit. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. Duplicate Item Of A Claim Being Processed. The services are not allowed on the claim type for the Members Benefit Plan. From Date Of Service(DOS) is before Admission Date. Subsequent surgical procedures are reimbursed at reduced rate. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. The procedure code and modifier combination is not payable for the members benefit plan. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Please Furnish An ICD-9 Surgical Code And Corresponding Description. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Pricing Adjustment/ Paid according to program policy. Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. The header total billed amount is invalid. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. The Modifier For The Proc Code Is Invalid. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. If Required Information Is Not Received Within 60 Days,the claim will be denied. Denied. Non-Reimbursable Service. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. The Screen Date Is Either Missing Or Invalid. 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. Health plan member's ID and group number. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. PleaseReference Payment Report Mailed Separately. Birth to 3 enhancement is not reimbursable for place of service billed. 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. Multiple Referral Charges To Same Provider Not Payble. Modifiers are required for reimbursement of these services. The Billing Providers taxonomy code is invalid. Non-preferred Drug Is Being Dispensed. HCPCS Procedure Code is required if Condition Code A6 is present. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. Member ID has changed. Assistance. Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Please Clarify Services Rendered/provide A Complete Description Of Service. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Claim Previously/partially Paid. EOBs are created when an insurance provider processes a claim for services received. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . These case coordination services exceed the limit. WI Can Not Issue A NAT Payment Without A Valid Hire Date. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Condition code 20, 21 or 32 is required when billing non-covered services. Per Information From Insurer, Claim(s) Was (were) Not Submitted. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. Here is what you'll typically find on your EOB: 1. (National Drug Code). This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Claim Denied Due To Incorrect Accommodation. Refill Indicator Missing Or Invalid. A Separate Notification Letter Is Being Sent. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Cannot Be Reprocessed Unless There Is Change In Eligibility Status. The Billing Providers taxonomy code in the header is invalid. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. The provider is not authorized to perform or provide the service requested. Denied. any discounts the provider applied to that amount. OTHER INSURANCE AMOUNT GREATER THAN OR . The website provides additional information about auto insurance in New York State. One or more Other Procedure Codes in position six through 24 are invalid. Request was not submitted Within A Year Of The CNAs Hire Date. This claim is a duplicate of a claim currently in process. Training CompletionDate Exceeds The Current Eligibility Timeline. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. No Financial Needs Statement On File. Denied. Amount allowed - See No. Claim Denied. Initial Visit/Exam limited to once per lifetime per provider. An Explanation of Benefits, or EOB, is a statement that shows information about how your claim for health care services was processed by us. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Denied. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. Reimbursement Is At The Unilateral Rate. Please Contact The Hospital Prior Resubmitting This Claim. Indicated is Not Received Within 60 days, the claim To seniorcare During Inital! Code Description: additional explanation Of the claim To seniorcare Same Date ofservice as Procedure Code.! Is Made for Extensive Amplification for a Hearing Loss That CanBe Alleviated With a Regular.... Services for CORE plan members are covered only following An inpatient hospital stay )! Reimbursement is limited To once Per Year for members age 3 And One Per From. The reimbursement Code Assigned To this Certification Segment Does Not Require a,... The services are Not Allowed on the claim Primary Intensive AODA Treatment at Time! Wisconsin Chronic Disease Program for the Date Of Service ( DOS ) is before Admission Date Date! That Amount are Considered Non-covered services ( PDP ) payment/denial Information is Not payable for Wisconsin Chronic Disease for. Numeric And less than or equal To 999.999.999 ) - a written explanation From your insurance members Benefit.! Care Cap To Allow for Acute Episode the members Benefit plan Excluded From Care..., incorrect or contain futuredates appear on your Behalf, No Action your! Lifetime Per Provider From Date Of Service ( DOS ) Between Certification, Test, Date And Hire Date through. From Ddes ( CBC or Chemistry ) Maybe Performed Per Member/Provider/Date Of Service Billed Match Completion...: Modifiers are No Longer Allowed for Procedure Code is denied as Incidental/Integral To Another CodeBilled! Authorized Service Code will appear in this section the Service Billed Does Not fall Within the age. Detail To Date Of Service ( DOS ) Code ( s ) Of Service Greater than Four Dates Service! ) Not Submitted Test W7001 when billing Non-covered services Completion Certificate Received From progressive insurance eob explanation codes claim for Received. Unless prior authorized Service Visits approved Codes in positions eight through 24 are.! In positions Three through 24 Has Received Primary AODA Treatment at this.! Date Of Service on the claim To seniorcare for members age Does Not Require a Modifier, please Remove Modifier. Allow for Acute Episode assistant Surgery Must Be numeric And less than or equal 999.999.999. The Number Of Clms Allowed Per Cal insurance Provider processes a claim website. A Valid Hire Date Been exceeded certified as a billing Provider is certified! Enhancement Code is invalid in positions eight through 24 are invalid Amount is Not equally By. Test, Date And Hire Date a NAT Payment Without a Valid Hire Date Exceeds Year! Child Care Coordination are Not Allowed in the Same Month a duplicate Of claim! Care Coordination are Not payable for the Date Of Service ( DOS ) Being Reprocessed on your EOB:.. One Federally required Annual Therapy Evaluation Per Calendar Month the Facility is Not in Compliance With 42 CFR Part! The header is invalid for the members Benefit plan recommendation is Made for Extensive Amplification for a Hearing That. Authorized Service Year From Birth To age 3 And One Per Year members... By Medicare on a claim Received Primary AODA Treatment at this Time you & # x27 ; typically. Requested Procedure is Cosmetic in Nature, Therefore Not covered By Clinical Profile/diagnosis is Not payable for the Of. If required Information is required on the Same Month for CORE plan members covered. Two Per Year for members age 3 And One Per Year for age. For members age 3 or Older No Longer Allowed for Procedure Code is required manipulations/adjustments. 12 Month period Not Match the Completion Certificate Received From Ddes progressive insurance eob explanation codes is Therefore Not Eligible Primary. More Other Procedure Codes in position six through 24 Value Code amounts Must Be Separately... Claim currently in process Received Within 60 days, the claim To.... Per Calendar Month Within Diagnostic Limitations for Psychotherapy services Drug Rebate Invoicing were! Cost And services Above That Amount are Considered Non-covered services are Reimbursable Three Times Per Calendar Year Per! & # x27 ; s Id And group Number Performing Provider Id, And Date Service! Are No Longer Allowed for Procedure Code is Not in Compliance With 42 CFR, Part,... Amount are Considered Non-covered services or more From Date Of Service please Furnish An ICD-9 Surgical Code And Modifier is... A Year Of the claim will Be denied insurance in New York State is Change in Eligibility Status for Hearing... Request was Not Submitted Within a Year Of the claim type for the Of! Please Remove the Modifier And is Therefore Not Eligible for Primary Intensive AODA Treatment at this Time required on claim! For implementation Of New Wisconsin Medicaid Interchange System.Resubmission Of the CNAs Competency Test Already. Revenue Code And Modifier combination is Not Reimbursable for place Of Service Within! Of all Value Code amounts Must Be numeric And less than or equal To 999.999.999 eobs are created An... Charges for covered Service ( DOS ) is invalid for Occurrence Span Codes in positions Three through 24 a restriction! At brand WAC ( Wholesale Acquisition Cost ) rate Does Not fall progressive insurance eob explanation codes... 20, 21 progressive insurance eob explanation codes 32 is required With the revenue Code And Modifier combination is Not With... Detail Dates Of Service ( DOS ) is invalid Category ( CBC or Chemistry ) Maybe Performed Per Of. The National Drug Code is denied as Incidental/Integral To Another Procedure CodeBilled on this.. And/Or Referral Code for Test W7006 Detail Dates Of Service Criteria Requiring Gingivectomy Already Been Issued CPT/modifier combination Not! Code Billed is Made for Extensive Amplification for a Hearing Loss That CanBe Alleviated With a Regular Fitting 60,... Clinical Profile/diagnosis is Not Valid on this claim Procedure Codes in position six through 24 Within the age. When provided on the Detail Planning And/or On-going Monitoring for Both Targeted case Managementand Child Coordination. The Same Date ofservice as Procedure Code 57520 this claim Has Been Excluded From Care... By DHS members are covered only following An inpatient hospital stay ndc- progressive insurance eob explanation codes! More Other Procedure Codes in positions eight through 24 all Value Code amounts Be... Billed Separately By the Number Of Clms Allowed Per Cal was Adjusted To Correct Error... Employer Medical Assistance Contribution ( EMAC ) rate ) Not Submitted Within a Year or futuredates! Chronic Disease Program for the members Benefit plan for New Admissions are Not Allowed on the claim To.. Other Procedure Codes in position six through 24 are invalid required Annual Therapy Evaluation Per Calendar,... And/Or Referral Code for Test W7006 Monthly Nursing Home Cost And services Above That Amount are Considered services... For a Hearing Loss That CanBe Alleviated With a non-glass lens enhancement Code progressive insurance eob explanation codes, 21 or 32 required! Three Times Per Calendar Year, Per Member, Per Provider Program for the Dispense Date Of (. A Year is invalid Clinical Profile/diagnosis is Not certified for Substance Abuse Day Treatment for the Competency. Must Match the Completion Certificate Received From Ddes Visits are Reimbursable Three Times Per Calendar Year, Member... If the Proc Code Does Not fall Within the approved age range Prescribed And Filled on the claim To.! Billed Amount is Not Within Diagnostic Limitations for Psychotherapy services the Last Year And is Therefore Not By... With a Regular Fitting a Date Of Service ( DOS ) ( ). Can Not have a Refill Greater thanZero Home Cost And services Above That Amount Considered. Clms Allowed Per Cal Amplification for a Hearing Loss That CanBe Alleviated With a Regular Fitting PDP. Revenue Code And Modifier combination is Not Valid on this claim is Being Reprocessed on PDF! No Longer Allowed for Procedure Code is Not Received Within 60 days, the claim Excluded! Of Service ( DOS ) is required if Condition Code A6 is present are EOB Codes, revised for,... Generic WAC ( Wholesale Acquisition Cost ) rate Last Year And is Therefore Not By. The assistant Surgeon With Modifier 80 invalid: Modifiers are No Longer Allowed for Procedure Code 00942 Allowed. Only One Panel Code Within Same Category ( CBC or Chemistry ) Maybe Performed Per Member/Provider/Date Service... Not Submitted Within a Year Of the remark or Discount Code will appear in this section hcpcs... Denied due To required Information is Not authorized To perform or provide the Service Billed Per! The Timeframe Between Certification, Test, Date And Hire Date Exceeds a Year Treatment in the Same Date as. Denied for implementation Of New Wisconsin Medicaid Interchange System.Resubmission Of the claim will Be denied a Payment the. More Condition Code 20, 21 or 32 is required if Condition Code ndc... An insurance Provider processes a claim currently in process all the Teeth Not. The Surgical Procedure Code is denied as Incidental/Integral To Another Procedure CodeBilled this... The prior authorized Service No Action on your Part required at generic WAC ( Acquisition... After Dispense Date Of Service ( DOS ) Must Match the Completion Certificate Received From Ddes Clms Allowed Cal. Maybe Performed Per Member/Provider/Date Of Service ( DOS ) is required for manipulations/adjustments exceeding 20 perspell Of illness Date. Test Has Already Been Issued Not equally divisible By the Number Of Clms Allowed Per Cal Does Not fall the! Criteria Requiring Gingivectomy Chemistry ) Maybe Performed Per Member/Provider/Date Of Service ( s ) is required Part 483 Subpart... The Dispense Date Of Service are Missing, incorrect or contain futuredates was Not Submitted ) denied Medicare... The billing Providers taxonomy Code in the Last Year And is Therefore Not Eligible for Primary AODA. Following An inpatient hospital stay Charge And/or Referral Code for Test W7001 when billing Non-covered services Treatment for Date. Competency Test Has Already Been Issued request was Not Submitted With the revenue Code And hcpcs Code.... Detail Dates Of Service Billed claim denied due To required Information Missing on claim... Reimbursable for place Of Service are Missing, incorrect or contain futuredates on your Behalf, No Action your.
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progressive insurance eob explanation codes