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Progressive Insurance Eob Explanation Codes. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Modifier invalid for Procedure Code billed. Please Resubmit Using Newborns Name And Number. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. As A Reminder, This Procedure Requires SSOP. This National Drug Code (NDC) is only payable as part of a compound drug. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. See Explanations box for an explanation of what the codes stand for. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Procedure Not Payable As Submitted. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Along with the EOB, you will see claim adjustment group codes. The Travel component for this service must be billed on the same claim as the associated service. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. This National Drug Code Has Diagnosis Restrictions. Traditional dispensing fee may be allowed. A valid Level of Effort is also required for pharmacuetical care reimbursement. If you owe the doctor, hospital or dentist, they'll send you an invoice. Oral exams or prophylaxis is limited to once per year unless prior authorized. Billed Amount Is Equal To The Reimbursement Rate. RULE 133.240. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Supervisory visits for Unskilled Cases allowed once per 60-day period. Please Bill Your Medicare Intermediary Prior To Submitting To . This Claim Is Being Returned. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. If required information is not received within 60 days, the claim will be. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Provider Documentation 4. Repackaging allowance is not allowed for unit dose NDCs. Correct Claim Or Resubmit With X-ray. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Claim Must Indicate A New Spell Of Illness And Date Of Onset. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. Fourth Other Surgical Code Date is required. This Is A Duplicate Request. Request was not submitted Within A Year Of The CNAs Hire Date. Professional Service code is invalid. Service(s) Denied/cutback. Other Insurance Disclaimer Code Invalid. Compound drugs not covered under this program. Extended Care Is Limited To 20 Hrs Per Day. Services Denied. You can easily access coupons about "If Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Please Contact The Surgeon Prior To Resubmitting this Claim. The amount in the Other Insurance field is invalid. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. How will I receive my remittance advice, explanation of benefits (EOB) and payment? Claim Is Being Special Handled, No Action On Your Part Required. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Reimbursement Based On Members County Of Residence. Use This Claim Number For Further Transactions. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. the V2781 to modify the meaning of the progressive. Other Medicare Managed Care Response not received within 120 days for providerbased bill. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. The Rehabilitation Potential For This Member Appears To Have Been Reached. Hospital discharge must be within 30 days of from Date Of Service(DOS). This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. Please Resubmit. Serviced Denied. This National Drug Code (NDC) is not covered. Claim Denied. The Comprehensive Community Support Program reimbursement limitations have been exceeded. HCPCS Procedure Code is required if Condition Code A6 is present. VA classifies all processed claims as accepted, denied, or rejected. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. If you have a complaint or are dissatisfied with a . This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Service(s) paid at the maximum daily amount per provider per member. Denied. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. The Third Occurrence Code Date is invalid. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Benefit Payment Determined By Fiscal Agent Review. The Fax number is (877) 213-7258. The Service Requested Is Inappropriate For The Members Diagnosis. This Surgical Code Has Encounter Indicator restrictions. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Service Denied/cutback. Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. Discharge Diagnosis 2 Is Not Applicable To Members Sex. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. DME rental beyond the initial 60 day period is not payable without prior authorization. The Procedure Code has Diagnosis restrictions. If Required Information Is not received within 60 days, the claim detail will be denied. Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. Dealing with Health Insurance that is Primary to CHAMPVA. Please File With Champus Carrier. This National Drug Code (NDC) has Encounter Indicator restrictions. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. Denied. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. PLEASE RESUBMIT CLAIM LATER. If the insurance company or other third-party payer has terminated coverage, the provider should Denied. Please Contact The Hospital Prior Resubmitting This Claim. Fifth Other Surgical Code Date is required. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. need eob for each carrier indicated on resource file 1 251 n4 286 034 22 mod.not justified 22 mod.services not justified/paid at unmodified rate 3 150 047 035 rebill correct hcpc asc,op fac/phys.billed diff code;rebill correct hcpc 2 16 . Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Birth to 3 enhancement is not reimbursable for place of service billed. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. 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. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. This is a duplicate claim. No Extractions Performed. Competency Test Date Is Not A Valid Date. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. The dental procedure code and tooth number combination is allowed only once per lifetime. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Denied due to Member Is Eligible For Medicare. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. . 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). Title 10, United States Code, Section 1095 - Authorizes the government to collect reasonable charges from third party payers for health care provided to beneficiaries. Members I.d. This drug is not covered for Core Plan members. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. The Member Does Not Appear To Meet The Severity Of Illness Indicators Established by the Wisconsin And Is Therefore Not Eligible For AODA Day Treatment. Contact your health insurance company if you have any questions about your EOB. Effective August 1 2020, the new process applies coding . Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Glucocorticoids-Inhaled to Flovent. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. Denied. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Total billed amount is less than the sum of the detail billed amounts. Please Submit On The Cms 1500 Using The Correct Hcpcs Code. Denied. Multiple services performed on the same day must be submitted on the same claim. . A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Unable To Process Your Adjustment Request due to Member Not Found. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. Claim Detail Denied Due To Required Information Missing On The Claim. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Prior Authorization Is Required For Payment Of This Service With This Modifier. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. Participant Is Enrolled In Medicare Part D. Beginning 09/01/06, Providers AreRequired To Bill Part D And Other Payers Prior To Seniorcare Or Seniorcare WillDeny The Claim. 0959: Denied . Admission Denied In Accordance With Pre-admission Review Criteria. A Training Payment Has Already Been Issued To Your NF For This CNA. Claim Denied Due To Invalid Pre-admission Review Number. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. Claim Denied. Rendering Provider is not certified for the From Date Of Service(DOS). Edentulous Alveoloplasty Requires Prior Authotization. Health plan member's ID and group number. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. A Version Of Software (PES) Was In Error. Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. (EOP) or explanation of benefits (EOB) . CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Payment Recouped. Glass lens enhancement code is not allowed with a non-glass lens enhancement code . Use This Claim Number If You Resubmit. The billing provider number is not on file. Your 1099 Liability Has Been Credited. Claim Denied For Future Date Of Service(DOS). Denied/Cutback. The Skills Of A Therapist Are Not Required To Maintain The Member. A Second Surgical Opinion Is Required For This Service. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Denied. First Other Surgical Code Date is invalid. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. A Rendering Provider is not required but was submitted on the claim. Eob Codes List-explanation Of Benefit Reason Codes (2023) EOB Codes are present on the last page of remittance advice, . This Is A Manual Decrease To Your Accounts Receivable Balance. Denied/Cutback. The respiratory care services billed on this claim exceed the limit. 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. Critical care performed in air ambulance requires medical necessity documentation with the claim. 100 Days Supply Opportunity. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Pricing Adjustment/ Maximum allowable fee pricing applied. 93000: Electrocardiogram . Pricing Adjustment/ Medicare crossover claim cutback applied. Service Denied. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. This Service Is Included In The Hospital Ancillary Reimbursement. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Denied. Covered By An HMO As A Private Insurance Plan. Member must receive this service from the state contractor if this is for incontinence or urological supplies. The Medicare Paid Amount is missing or incorrect. Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Denied. Surgical Procedure Code is not related to Principal Diagnosis Code. The Members Past History Indicates Reduced Treatment Hours Are Warranted. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. Unable To Process Your Adjustment Request due to Member ID Not Present. Denied due to Detail Add Dates Not In MM/DD Format. Header To Date Of Service(DOS) is invalid. An Explanation of Benefits (EOB) . Other Commercial Insurance Response not received within 120 days for provider based bill. Pricing Adjustment/ Medicare pricing cutbacks applied. Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Pricing Adjustment/ Anesthesia pricing applied. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Request Denied Due To Late Billing. Member is assigned to an Inpatient Hospital provider. Other payer patient responsibility grouping submitted incorrectly. The Billing Providers taxonomy code is invalid. 13703. Diagnosis Code is restricted by member age. The Sixth Diagnosis Code (dx) is invalid. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. Please Rebill Only CoveredDates. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. This Mutually Exclusive Procedure Code Remains Denied. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Questionable Long-term Prognosis Due To Poor Oral Hygiene. Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). Claim or Adjustment received beyond 365-day filing deadline. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. Previously Denied Claims Are To Be Resubmitted As New-day Claims. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. Pharmaceutical care code must be billed with a valid Level of Effort. Valid Numbers Are Important For DUR Purposes. Service paid in accordance with program requirements. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Insufficient Documentation To Support The Request. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Assistance. This Service Is Covered Only In Emergency Situations. Reimbursement For Training Is One Time Only. Admit Diagnosis Code is invalid for the Date(s) of Service. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Header To Date Of Service(DOS) is after the ICN Date. Denied. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. No Interim Billing Allowed On Or After 01-01-86. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. The diagnosis code is not reimbursable for the claim type submitted. Third modifier code is invalid for Date Of Service(DOS). Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Separate reimbursement for drugs included in the composite rate is not allowed. Remarks - If you see a code or a number here, look at the remark. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. The header total billed amount is invalid. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. This Procedure Code Is Not Valid In The Pharmacy Pos System. Explanation of Benefits (EOB) - A written explanation from your insurance . Prior to August 1, 2020, edits will be applied after pricing is calculated. Please Verify That Physician Has No DEA Number. 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. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. Reimbursement For IUD Insertion Includes The Office Visit. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization.

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