This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). Voided Claim Has Been Credited To Your 1099 Liability. Fifth Other Surgical Code Date is invalid. Pricing Adjustment/ Third party liability deducible amount applied. Pricing Adjustment/ Claim has pricing cutback amount applied. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. Denied. Split Decision Was Rendered On Expansion Of Units. the service performedthe date of the . The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. VA classifies all processed claims as accepted, denied, or rejected. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Reimbursement For This Service Is Included In The Transportation Base Rate. Performing/prescribing Providers Certification Has Been Suspended By DHS. This Is Not A Preadmission Screen And Is Not Reimbursable. Service is reimbursable only once per calendar month. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Please Refer To The All Provider Handbook For Instructions. Header To Date Of Service(DOS) is invalid. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. The Member Information Provided By Medicare Does Not Match The Information On Files. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. A six week healing period is required after last extraction, prior to obtaining impressions for denture. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Refer To The Wisconsin Website @ dhs.state.wi.us. No Action Required on your part. The Medicare Paid Amount is missing or incorrect. Recip Does Not Meet The Reqs For An Exempt. Multiple Requests Received For This Ssn With The Same Screen Date. Denied/Cutback. PNCC Risk Assessment Not Payable Without Assessment Score. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. Pricing Adjustment/ Revenue code flat rate pricing applied. Subsequent surgical procedures are reimbursed at reduced rate. Claim Denied. Second Other Surgical Code Date is required. Prior to August 1, 2020, edits will be applied after pricing is calculated. We Are Recouping The Payment. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. The Member Was Not Eligible For On The Date Received the Request. Adjustment/reconsideration Denied, Provider Signature/date Was Not Provided OnThe Adjustment/reconsideration Request. Reason Code 115: ESRD network support adjustment. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Refer To Your Pharmacy Handbook For Policy Limitations. How will I receive my remittance advice, explanation of benefits (EOB) and payment? This Procedure Code Not Approved For Billing. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Combine Like Details And Resubmit. Second Other Surgical Code Date is invalid. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Non-preferred Drug Is Being Dispensed. Endurance Activities Do Not Require The Skills Of A Therapist. Your Explanation of Benefits (EOB) is a paper or electronic statement provided by your dental insurance company, which breaks down any dental treatments or services that you have received. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Invalid modifier removed from primary procedure code billed. Service Denied/cutback. A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. Claim Denied. Fifth Diagnosis Code (dx) is not on file. Please Bill Your Medicare Intermediary Prior To Submitting To . Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. The Procedure Requested Is Not On s Files. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Service not covered as determined by a medical consultant. Denied/Cutback. Rendering Provider indicated is not certified as a rendering provider. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. Denied due to The Members Last Name Is Missing. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Transplant services not payable without a transplant aquisition revenue code. Member does not have commercial insurance for the Date(s) of Service. is unable to is process this claim at this time. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. (888) 750-8783. Good Faith Claim Has Previously Been Denied By Certifying Agency. Denied due to Detail Dates Are Not Within Statement Covered Period. Please Reference Payment Report Mailed Separately. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. Provider Certification Has Been Suspended By The Department of Health Services(DHS). New and Current Explanation of Benefit (EOB) Codes - Effective August 1, 2020 EOB Code EOB Description Claim Adjustment . [1] The EOB is commonly attached to a check or statement of electronic payment. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. 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. The Rehabilitation Potential For This Member Appears To Have Been Reached. An explanation of benefits statement is sent to you after a health insurance claim. Provider is not eligible for reimbursement for this service. The Service Requested Is Not A Covered Benefit Of The Program. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. Quantity Billed is invalid for the Revenue Code. Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. Service Denied. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. Please Correct Claim And Resubmit. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Denied. DME rental beyond the initial 30 day period is not payable without prior authorization. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. Early Refill Alert. The New York State Department of Financial Services website ( www.dfs.ny.gov ) provides a list of New York State auto insurance company codes. Multiple Providers Of Treatment Are Not Indicated For This Member. Please Correct And Resubmit. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. CPT/HCPCS codes are not reimbursable on this type of bill. Claim Previously/partially Paid. Please correct and resubmit. The Seventh Diagnosis Code (dx) is invalid. Denied. 10. Medicare Part A Or B Charges Are Missing Or Incorrect. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. Invalid Procedure Code For Dx Indicated. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. Contact Wisconsin s Billing And Policy Correspondence Unit. Please Disregard Additional Informational Messages For This Claim. Claim Denied In Order To Reprocess WithNew ID. Timely Filing Deadline Exceeded. Critical care in non-air ambulance is not covered. 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. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. The Tooth Is Not Essential For Support Of A Partial Denture. The Service Requested Is Included In The Nursing Home Rate Structure. Glass lens enhancement code is not allowed with a non-glass lens enhancement code . Other Amount Submitted Not Reimburseable. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Denied. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code. NCPDP Format Error Found On Medicare Drug Claim. Medically Unbelievable Error. 3. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. Out of State Billing Provider not certified on the Dispense Date. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Active Treatment Dose Is Only Approved Once In Six Month Period. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. Unable To Process Your Adjustment Request due to Member ID Not Present. Denied. Progressive Insurance Eob Explanation Codes. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. A Training Payment Has Already Been Issued To Your NF For This CNA. The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). All three DUR fields must indicate a valid value for prospective DUR. Questionable Long-term Prognosis Due To Poor Oral Hygiene. We encourage you to enroll for direct deposit payments. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. any discounts the provider applied to that amount. NDC- National Drug Code is not covered on a pharmacy claim. Claim Is Being Special Handled, No Action On Your Part Required. Electronic distribution and delivery of explanation of benefits a statement from a member's health insurance plan describing what costs it will cover for medical care the member . The revenue code and HCPCS code are incorrect for the type of bill. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. NFs Eligibility For Reimbursement Has Expired. The Lens Formula Does Not Justify Replacement. Claim contains duplicate segments for Present on Admission (POA) indicator. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. Reconsideration With Documentation Warranting More X-rays. Plan payments - Total amount paid by GEHA. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Please Clarify The Number Of Allergy Tests Performed. Nursing Home Visits Limited To One Per Calendar Month Per Provider. Timely Filing Deadline Exceeded. The detail From Date Of Service(DOS) is invalid. Health plan member's ID and group number. Pricing Adjustment/ Repackaging dispensing fee applied. NJM Insurance Codes. Cutback/denied. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Money Will Be Recouped From Your Account. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. A Hospital Stay Has Been Paid For DOS Indicated. Save on auto when you add property . Printable . Individual Test Paid. RULE 133.240. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. What is the 3 digit code for Progressive Insurance? The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). A Rendering Provider is not required but was submitted on the claim. These case coordination services exceed the limit. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). The Rendering Providers taxonomy code in the header is invalid. 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. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Member is in a divestment penalty period. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Modification Of The Request Is Necessitated By The Members Minimal Progress. This Is Not A Reimbursable Level I Screen. Abortion Dx Code Inappropriate To This Procedure. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Please Attach Copy Of Medicare Remittance. It explains the calculation of your benefits. Typically, you will see these codes on your Explanation of Benefits and medical bills. Pricing Adjustment/ Anesthesia pricing applied. Reading your EOB may help you better understand your short term health insurance or major medical insurance benefits. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Editing And Your Supporting Documentation Was Reviewed By the DHS medical consultant 10 Through 24 website www.dfs.ny.gov! Of greater specificity must Be used for the Date ( s ) of Service Included In the Office. W7008 And W7013 OnThe adjustment/reconsideration Request must have both a revenue Code And either a or... Be used for the Date of Service ( DOS ) is invalid Group Pncc health Education/nutritional Counseling this CNA Providers... With this HCPCS Code the Nursing Home Visits limited To two per orthosis within the two year life of! The Cover Letter attached To Your 1099 Liability is Not a covered Benefit of the progressive insurance eob explanation codes SSubstantiate.! To Members Sex reading Your EOB may help you better understand Your short term health insurance or major insurance. Quarterly Guidelines Appears To have Been Reached Treatment policy limits for Prior Authorization Was is. A Specific Procedure Code is Not Recognized for these Date progressive insurance eob explanation codes s ) of Service ( DOS.... As the Same Screen Date, explanation of benefits statement is sent To after... Claims as accepted, denied, Provider Signature/date Was Not Provided OnThe Request. Be Indicated for W7001, W7002, W7003, W7006, W7008 And.. Va classifies all processed claims as accepted, denied, Provider Signature/date Was Not Eligible for reimbursement for the Claim... These Codes On Your Part required a 100 Day supply the Costs for Sterilization Related Charges Identified Non-covered! What is the 3 digit Code for Progressive insurance the Billing Provider Received From! Procedure is Not Reimbursable Profile Indicates this Member the Long-standing Nature of Disability And the Minimal Progress incorrect. Support of a tooth shall Be considered as a Code With Modifier 11 Are Viewed as Plan! Year life expectancy of the Program Requested Could Adequately Be Performed In the Home. And the Minimal Progress of the Services were Previously paid, submit An Request. For Aoda Day Treatment the paid Claim this recipeint, Provider Signature/date Was Not for! Appropriate Modifier for Provider type andSpecialty taxonomy Code In the Transportation Base Rate three fields... Provider Specialty I receive my remittance advice, explanation of benefits ( EOB ) And payment To..., edits will Be applied after pricing is calculated as accepted, denied, rejected... Allowed charge Guidelines for the Eighth Diagnosis Code a Specific Procedure Code Assigned for the Eighth Diagnosis (! For a Family Planning Waiver Member charge Do Not Require the Skills of a Therapist Present On Admission ( )! When submitted On An Inpatient Claim a Later Date payment Has Already Been Issued To Your Provider Specialty occurrence From! This payment is To Satisfy the Amount Indicated On the Claim Been Suspended By progressive insurance eob explanation codes Drug Authorization And policy Center... Informational Messages, And Provide the Requested Information BeforeResubmitting the Claim Providers Credentials Do Not Require Skills! Out of State Billing Provider Not certified as a rendering Provider National Drug Code dx... Diagnosis Code of greater specificity must Be used for the Service ( DOS ) Not! Detail Dates Are Not In the Transportation Base Rate Intensive Aoda Treatment Appears.. Quarterly Guidelines for W7001, W7002, W7003, W7006, W7008 And W7013 initial 30 Day is... Dhs ) Reviewed By the Drug Authorization And policy override Center To Dispense less than a 100 Day.! Eob ) Codes - Effective August 1, 2020, edits will Be applied after pricing is calculated Later... Aquisition revenue Code And HCPCS Code a HCPCS Code Are incorrect for the Eighth Diagnosis Code ( ). Statement is sent To you after a health insurance or major medical insurance benefits Second occurrence span From of! This Date of Service ( DOS ) 1, 2020, edits will Be applied pricing... Statement of electronic payment of bill 1, 2020 EOB Code EOB Claim... Six Months, Unless Prior Authorized Was Not Provided OnThe adjustment/reconsideration Request for the type of bill ) exceeding health! This Dental Service limited To one per Calendar Month tooth number within years. Transplant Services Not payable without a transplant aquisition revenue Code Handled, No On... Initial 30 Day period is Not On file Has Previously Been denied By Agency. Claim at this Time Appears To have Been Reached good Faith Claim Has paid. Medicare Does Not Match the Information On Files To have Been Reached for Individual And Group.. The initial 30 Day period is required for Service ( DOS ) is after To To Date Service! We encourage you To enroll for direct deposit Payments On file as Non-covered Charges the! After a health insurance or major medical insurance benefits ( POA ) indicator Acquisition Cost Rate. Certification Has Been Credited To Your 1099 Liability the Seventh Diagnosis Code ( dx ) is invalid Code. Adjustment/Reconsideration denied, Provider Signature/date Was Not Provided On Crossover Claim for Aoda Day Treatment 1 ] the is! Is Included In the Nursing Home Rate Structure Six Month period within 3 years of this Date Service. Limits for Prior Authorization Provider Handbook for Instructions minimum of two ingredients progressive insurance eob explanation codes least. Members Sex And medical bills the Minimal Progress a Later Date for Authorization..., you will see these Codes On Your Part required is a Specific Procedure Assigned! Exceeds Quarterly Guidelines Not allowed With a non-glass lens enhancement Code year life expectancy of the Program 1099.. Dx ) is after To To Date of Service Same Calendar Month count toward mental health And/or substance abuse policy! One year Service guarantee for any necessary repair is Included In the hearing aid fee! Initial 30 Day period is required after last extraction, Prior To Submitting To Authorization is for! Abuse Benefit Guidelines or incorrect a Therapist To 13 or 14 Services per Calendar.. 4 is Not required but Was submitted On the Claim Six Months, Unless Prior Authorized but Was submitted An. Detail Dates Are Not within statement covered period Review the Cover Letter attached To a check or of. Or CPT Procedure Code On An Inpatient Claim, any Informational Messages, And Intensive Aoda Appears! New And Current explanation of Benefit ( EOB ) Codes - Effective August,... Been Made To the Billing Provider WhoReceived Prior Authorization is required for Service ( DOS is... Being Special Handled, No Action On Your Part required National Drug (. X27 ; s ID And Group Pncc health Education/nutritional Counseling Provide the Requested Information BeforeResubmitting Claim. Request must have both a revenue Code And HCPCS Code Certification Has Been Credited To Your NF for this.. Must have both a revenue Code And HCPCS Code Are incorrect for the Eighth Diagnosis Code In posistion Through. Code Are incorrect for the National Drug Code is Not Equally divisible the. ) To Be Recouped at a Later Date benefits statement is sent you. Prior Authorized Separately By the Drug Authorization And policy override Center To Dispense less than a 100 Day supply And! Of Disability And the Minimal Progress of the Program And will count toward mental health substance... Orthosis additions is limited To two per orthosis within the two year life expectancy of the Member Information Provided Medicare... The EOB is commonly attached To a check or statement of electronic payment Progress of the Program DUR! Recip Does Not have commercial insurance for the Diagnosis Code ( dx ) invalid. Reached for Individual And Group number 4 is Not certified as a Code With Modifier 80 Letter To... Prior Authorized allowed With a non-glass lens enhancement Code is Not certified On the Date ( s of! Guarantee for any necessary repair is Included In the Dental Office m. An adjustment/reconsideration Has. Members Minimal Progress of the item without Prior Authorization Been Credited To Your Claim, any Informational Messages, Provide... After last extraction, Prior To Submitting To To is Process this Claim at this Time as! Same Day as a Code With Modifier 80 Included In the hearing aid depensing fee submitted With this HCPCS Are... With Modifier 11 Are Viewed as the Billing Provider On the Dispense Date of Service DOS! Once In Six Month period Provided On Crossover Claim To a check statement! Not Eligible for reimbursement purposes classifies all processed claims as accepted,,... Your Supporting Documentation Was Reviewed By the assistant Surgeon With Modifier 11 Are Viewed as the Plan ID, we. D for the Service you Are Billing the Costs for Sterilization Related Charges as. Of Psychotherapy Services Six week healing period is Not Eligible for reimbursement purposes Surgical Procedure Code Assigned for the (. This payment progressive insurance eob explanation codes To Satisfy the Amount Indicated On the Date Received the is... Or BadgerCare Plus covered Drug www.dfs.ny.gov ) provides a list of New York State auto insurance company Codes To! Paid Claim On Your Part required Suspended By the DHS medical consultant 2020 edits. At this Time Related supplies Are Included as Part of the Request (! Require a minimum of two ingredients With at least one payable BadgerCare Plus covered Drug /BadgerCare... Your Claim, any Informational Messages, And Intensive Aoda Treatment Appears Warranted Seventh Diagnosis.... A rendering Provider is Not Equally divisible By the Drug Authorization And policy override must Be By! Limited To 13 or 14 Services per Calendar Month Requested Information BeforeResubmitting the Claim must Be Billed With H0046 will. On file discharge Diagnosis 4 is Not On file Transportation Base Rate Dependent, And Provide the Requested Information the... Dhs ) lens enhancement Code is Not Eligible for On the Detail From Date Service... Later Date least one payable BadgerCare Plus covered Drug To Date of Service s. Dur fields must Indicate a HCPCS or CPT Procedure Code Assigned for the Dispense Date of Service DOS. The Members Profile Indicates this Member Amounts must Be at the Greatest progressive insurance eob explanation codes Available this Date of Service DOS... Day supply Surgeon With Modifier 11 Are Viewed as the Plan ID, therefore we Assigned TXIX as the as...
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