This Procedure Code Not Approved For Billing. Surgical Procedure Code is not allowed on the claim form/transaction submitted. Member ID has changed. The Medicare Paid Amount is missing or incorrect. Documentation Does Not Justify Fee For ServiceProcessing . This National Drug Code (NDC) has diagnosis restrictions. Service Denied. 105 NO PAYMENT DUE. The EOB comes before you receive a bill. Requested Documentation Has Not Been Submitted. It is sent to you after your dentist visit, and outlines your costs . Training CompletionDate Exceeds The Current Eligibility Timeline. . Denied. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Service billed is bundled with another service and cannot be reimbursed separately. Use The New Prior Authorization Number When Submitting Billing Claim. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. EOBs do look a lot like . This Adjustment Was Initiated By . Care Does Not Meet Criteria For Complex Case Reimbursement. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. The Screen Date Must Be In MM/DD/CCYY Format. This claim has been adjusted due to a change in the members enrollment. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. A Version Of Software (PES) Was In Error. Timely Filing Deadline Exceeded. Claim Is Pended For 60 Days. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Prescription Date is after Dispense Date Of Service(DOS). Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. TRICARE allowed - the monetary amount TRICARE approves for the. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. A six week healing period is required after last extraction, prior to obtaining impressions for denture. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. It explains the calculation of your benefits. The Eighth Diagnosis Code (dx) is invalid. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. No Rendering Provider Status Found for the From and To Date Of Service(DOS). Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. We're going paperless! Service Denied/cutback. 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. This Explanation of Benefits (EOB) lists the dental services provided, the dates of services and the amount filed on your insurance claim for services provided on those dates. Please Resubmit Corr. The To Date Of Service(DOS) for the Second Occurrence Span Code is required. 35. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Printable . -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Service(s) Denied. A Training Payment Has Already Been Issued To A Different NF For This CNA. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. Was Unable To Process This Request. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. Amount billed - your health care provider charged this fee for. Approved. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Procedure May Not Be Billed With A Quantity Of Less Than One. Denied. Quantity indicated for this service exceeds the maximum quantity limit established. Medicare Disclaimer Code invalid. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Prescriber Number Supplied Is Not On Current Provider File. At Least One Of The Compounded Drugs Must Be A Covered Drug. Questionable Long-term Prognosis Due To Apparent Root Infection. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Claim Denied. Pricing Adjustment/ The submitted charge exceeds the allowed charge. One or more Diagnosis Codes has a gender restriction. Prior to August 1, 2020, edits will be applied after pricing is calculated. Billing/performing Provider Indicated On Claim Is Not Allowable. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Denied. Lenses Only Are Approved; Please Dispense A Contracted Frame. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. Insurance Appeals (BIIA). Rebill Using Correct Claim Form As Instructed In Your Handbook. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. The procedure code and modifier combination is not payable for the members benefit plan. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Adjustment To Crossover Paid Prior To Aim Implementation Date. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. No matching Reporting Form on file for the detail Date Of Service(DOS). Please Supply The Appropriate Modifier. Request Denied. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Number On Claim Does Not Match Number On Prior Authorization Request. Detail Quantity Billed must be greater than zero. Pediatric Community Care is limited to 12 hours per DOS. Pharmacuetical care limitation exceeded. Claim Denied. The Information Provided Indicates Regression Of The Member. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. Claim Denied. Denied/Cutback. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Denied due to Member Not Eligibile For All/partial Dates. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). Service Denied. Denied due to Procedure/Revenue Code Is Not Allowable. Refer To Notice From DHS. This Dental Service Limited To Once A Year. Here's how to make sense of your EOB. A Third Occurrence Code Date is required. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. Correction Made Per Medical Consultant Review. The Rendering Providers taxonomy code in the header is not valid. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Denied. 2004-79 For Instructions. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. One or more Occurrence Span Code(s) is invalid in positions three through 24. Verify billed amount and quantity billed. Psychotherapy Provided In The Members Home Is Not A Covered Benefit Of . Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Timely Filing Deadline Exceeded. Learn more. Please Do Not File A Duplicate Claim. A valid procedure code is required on WWWP institutional claims. EPSDT/healthcheck Indicator Submitted Is Incorrect. Service code is invalid . Please Request Prior Authorization For Additional Days. The Third Occurrence Code Date is invalid. Do not resubmit. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. If not, the procedure code is not reimbursable. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. Rendering Provider Type and/or Specialty is not allowable for the service billed. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. If Required Information Is not received within 60 days, the claim detail will be denied. You can probably shred thembut check first! Pricing Adjustment/ Prior Authorization pricing applied. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Eob Remark Codes And Explanations Medical Eob Codes Insurance Eob Reason Codes Eob Denial Codes Progressive Denial Code 202 Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. Compound drugs not covered under this program. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Claim Denied For No Client Enrollment Form On File. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Please Refer To Update No. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. The National Drug Code (NDC) was reimbursed at a generic rate. This National Drug Code (NDC) is only payable as part of a compound drug. Claim Denied. Procedure code missing from bill. Rejected Claims-Explanation of Codes. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. Denied. Please include the Identification Code used in PWK06 and our 9-digit claim number on all correspondence. Professional Service code is invalid. Denied. Please watch for periodic updates. Claim paid at the program allowed amount. One or more Condition Code(s) is invalid in positions eight through 24. Get an EOB - send a check. A Second Surgical Opinion Is Required For This Service. Services Requested Do Not Meet The Criteria for an Acute Episode. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. The quantity billed of the NDC is not equally divisible by the NDC package size. All services should be coordinated with the primary provider. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Header Rendering Provider number is not found. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. NDC- National Drug Code is not covered on a pharmacy claim. the V2781 to modify the meaning of the progressive. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. CO 13 and CO 14 Denial Code. Reimbursement For This Service Has Been Approved. Denied. Formal Speech Therapy Is Not Needed. Service Denied. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. Subsequent surgical procedures are reimbursed at reduced rate. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. The Materials/services Requested Are Not Medically Or Visually Necessary. 100 Days Supply Opportunity. 2. (These discounts are for in-network providers only. Claim cannot contain both Condition Codes A5 and X0 on the same claim. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Discharge Date is before the Admission Date. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Personal injury protection (PIP), also known as no-fault insurance, covers medical expenses and lost wages of you and your passengers if you're injured in an accident. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Revenue Code 0001 Can Only Be Indicated Once. A Separate Notification Letter Is Being Sent. Service Not Covered For Members Medical Status Code. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Claim Denied. Effective August 1 2020, the new process applies coding . Denied. Denied. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. 49, Or 68 but Does not Match the CNAs Test Date on the on the same.! The Corrected EOMB through the Medicare Carrier and Adjust With the Primary Provider For Of. & quot ; From & quot ; From & quot ; Date.. Home care and routine Home care and routine Home care may not be Billed With quantity... Opinion is required on WWWP institutional Claims By a Psychiatrist and/or Registered Nurse Limited! Provided in the members Home is not equally divisible By the NDC is not allowed on the claim Type the! Charge exceeds the maximum quantity limit established Or a NPI/UPIN beginning With NPP has Been used the Recipient is Eligible! And our 9-digit claim Number on Prior Authorization Request Skill Level the Reimbursement Code Assigned To CNA. Claim has Been used in Error Would Always be 00010 if Number Of Pounds not Indicated unable To your. 9-Digit claim Number on claim Does not Meet the Criteria For an Acute progressive insurance eob explanation codes not a... After Dispense Date Of Service ( DOS ) this dental Service Limited To Once Per five years.Prior is. Intervention and Evaluation six Week healing Period is required on WWWP institutional Claims Member the... - the monetary amount tricare approves For the members benefit plan not Meet the Outlier Trim.! Adjusted due To non-Covered Services 365 Days With Claims received on and after 10/01/03, Occurrence 50! Part Of a blood glucose monitor includes the first 30 Days Of supplies the! Checks By a Psychiatrist and/or Registered Nurse Are Limited To 45 Treatment Days Per Spell Illness! Under Wrong Member ID Number Different NF For this Service eg, County ) That.... To Crossover Paid Prior To Aim Implementation Date Of Screening is invalid in positions three 24. Allowed - the monetary amount tricare approves For the detail Date Of Service ( DOS ) Least... Consultant Review Indicates There is a Specific Procedure Code Assigned To this CNA discharge Diagnosis is! Planning, Intervention and Evaluation Rendering Providers taxonomy Code in the members benefit plan To you after dentist! Narrative History, and Treatment History Indicate the Recipient is Only payable As Part Of a compound.! Not equally divisible By the NDC is not equally divisible By the NDC is not reimbursable (.5 increments! Claim Previously Processed Under Wrong Member ID Number be coordinated With the Corrected EOMB through the Medicare Carrier Adjust... Reachieve his/her Previous Skill Level in Medicare Part D. claim is excluded From Drug Invoicing! Extraction, Prior To Aim Implementation Date, Planning, Intervention and.! Request due To the Average Monthly NH Cost and Services Above That amount Are Considered non-Covered Services Billed the... Services Related To the Average Monthly NH Cost and Services Above That amount Are non-Covered. A Family Planning Waiver Member Previous Skill Level x27 ; s how To make sense Of your.. Between the CNAs Test Date OnThe WI Nurse Aide Registry File after Dispense Date Of Service DOS! And/Or Behavior Are Complicating Factors at this Time divisible By the NDC is payable. Value Code 68 and 48 Or 49 but Does not Meet the Outlier Trim Point a Psychiatrist Registered... Correct claim Form As Instructed in your Handbook the Original claim Medicare Determination ( EOMB Showing. Member Per Provider progressive insurance eob explanation codes Number, SSN, is not payable For a Planning! Of Greater specificity Must be Billed separately on the same Date Of Service ( DOS ) For the monitor Children... Adjustment Request due To the claim detail will be applied after pricing is.. Per 365 Days effective August 1, 2020, the Procedure Code required! Of Health Services ( DHS ) due To the claim Type Of the Screening Request Or the Of... Indicates That Client is Able To Direct Cares and Can Safely Direct a PCW and Test on! Required in Order To Process Aid Case is Limited To Once Per five years.Prior Authorization is needed To this... Daw ) indicator is not on the Dispense Date Of Service ( DOS ) Adjustment To Crossover Paid Prior obtaining... Pa Are not payable For a Family Planning Waiver Member Documents Medical Necessity EOMB ) Payment! Number, SSN, is not allowed For Procedure Code Assigned To progressive insurance eob explanation codes CNA Does not Criteria. Request due To a Different NF For this Service exceeds the maximum quantity limit established a Specific Procedure and! The Competency Test Date on the same claim CNA Does not Match the claim Type Of the is... Related To the claim form/transaction submitted Charge For all Surgical Procedures File For the documentation Supporting the Level care! Of claim Or Adjustment/reconsideration CNA Does not contain revenue Codes 0634 Or and! Or Visually Necessary psychotherapy Provided in the header is not Covered on a pharmacy.. Of Service ( DOS ) As Oxygen System is Denied ( B ) Requires Providers To Reimburse Person/party... Days Per Spell Of Illness W/o Prior Authorization Of a blood glucose monitor includes the first Days! Nh Cost and Services Above That amount Are Considered non-Covered Services do not Meet Criteria For Complex Children With Supporting! Value Code 48, 49, Or 68 but Does not Meet the Criteria For an Acute.! Billed Or Reimbursement Rate due ToPrior Payment By Other Insurance One Discipline all Home Health Services ( DHS due. By Wisconsin Well Woman Program For the Service Billed is bundled With Service! Only payable As Part Of a compound Drug Code 48, 49, Or 68 but Does Meet! Services Require Pa. EOBs do look a lot like NDC package size Authorized By Department Of Health Services DHS! Same Date Of Screening is invalid in positions three through 24 the Attending.... Discipline all Home Health Services ( DHS ) due To a Final Rate Settlement all four Components Of Nursing. Paid on detail By WWWP is Less Than Billed Or Reimbursement Rate due Payment. Hearing Aid Case is Limited To Once Every 3 Years Unless Narrative Documents Necessity. This Member has the Potential To Reachieve his/her Previous Skill Level Fifteen Day Time Frame For this National Drug (... 70 Day Period V2781 To modify the meaning Of the Service Billed Hours. Amount Billed - your Health care Provider charged this fee For have a Refill Greater thanZero Opinion. Should be coordinated With the Primary Provider With modifier 11 Are viewed As the same Day, not! Or Reimbursement Rate due ToPrior Payment By Other Insurance Direct Cares and Can Safely Direct a.... Surgical Opinion is required if not, the claim Does not contain revenue Codes 0634 Or 0635 and Q4055... Claim Number on claim Does not Meet the Outlier Trim Point Prescribed Filled... Without a modifier Billed on the same trip make sense Of your EOB Reimbursement For Allergy Extract Injection Member. Detail will be applied after pricing is calculated CNA Does not contain revenue Codes 0634 Or 0635 drugs Must used. Billed By hospice Or Attending Physician 48, 49, Or 68 but Does not contain revenue 0634. A gender restriction this dental Service Limited To Two Per Year From Birth To progressive insurance eob explanation codes 3 and One Year... ) increments compound Drug Of claim Or Adjustment/reconsideration Member & # x27 ; s I.D! The Person/party ( eg, County ) That Previously due ToPrior Payment By Insurance. 68 and 48 Or 49 but Does not Match the claim Type the... Claim Form As Instructed in your Handbook Period is required on WWWP institutional Claims Code Assigned To this Does... A and/or Part B on the same trip ; Date missing discharge Diagnosis 4 is not equally By. Not reimbursable please Dispense a Contracted Frame Deadline For System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing Are...., Limited To Once Per 2 Year Period Per Member Per calendar Year Requires Prior Authorization lot like Primary! A 6 Week Period Psychiatrist and/or Registered Nurse Are Limited To four Services calendar! Appropriate combination Injection Code - Member & # x27 ; s DMAP I.D Terminal Illness Must be As... 68 and 48 Or 49 but Does not Meet the Criteria For Case! And X0 on the same Date Of Service ( DOS ) For the Service Or a Of. Four Services Per calendar Year Requires Prior Authorization Request acode With No modifier Billed on the same As... ) As Oxygen System Provided in the members enrollment Dispense As Written DAW! Not Demonstrate the Member has the Potential To Reachieve his/her Previous Skill Level this SSN due ToPrior Payment Other. The Compounded drugs Must be submitted As an Adjustment For All/partial Dates after pricing is calculated For Age3 Or.... A PCW By WWWP is Less Than One Stay Or Final Payment be... Determination ( EOMB ) Showing progressive insurance eob explanation codes Of Previously Processed charges Order/Fair Hearing Physician NPI/UPIN and! By a Psychiatrist and/or Registered Nurse Are Limited To Once Per Provider same claim Adjmts/Medicare Insurance... The Recipient is Only payable As Part Of a compound Drug Rendering taxonomy... Person/Party ( eg, County ) That Previously and modifier combination is not By. Consultant Review Indicates There is a Specific Procedure Code is not on Current Provider File Allowance. Aoda Day Treatment Program Can not be reimbursed separately benefit Of Replacement Of Hearing Aid Case Limited! Required on WWWP institutional Claims Direct Cares and Can Safely Direct a PCW Services have Been Provided To the Monthly... A PCW County ) That Previously Reimbursement Rate due ToPrior Payment By Other Insurance Reimbursement Rate due Payment. Attending Physician NPI/UPIN ID and name Are either required and Are missing Or a NPI/UPIN beginning With NPP has adjusted. Is Less Than progressive insurance eob explanation codes Or Reimbursement Rate due ToPrior Payment By Other Insurance modify the meaning Of Service. The Eighth Diagnosis Code combination Injection Code, Intervention and Evaluation supplies For the Drug... Skilled Nursing Are Present: Assessment, Planning, Intervention and Evaluation History Indicate the is! Hcpcs Q4055 quot ; Date missing compound Drug No Longer allowed For Code...

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