Denied. Other payer patient responsibility grouping submitted incorrectly. Claim Denied. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. Procedure Code and modifiers billed must match approved PA. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Timely Filing Deadline Exceeded. Medical Billing and Coding Information Guide. Please Indicate The Dollar Amount Requested For The Service(s) Requested. One or more Surgical Code(s) is invalid in positions six through 23. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. CO 13 and CO 14 Denial Code. Valid NCPDP Other Payer Reject Code(s) required. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Please include the Identification Code used in PWK06 and our 9-digit claim number on all correspondence. The Service Requested Is Not Medically Necessary. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Denied due to Statement Covered Period Is Missing Or Invalid. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). A quantity dispensed is required. Prior to August 1, 2020, edits will be applied after pricing is calculated. Surgical Procedures May Only Be Billed With A Whole Number Quantity. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Do not leave blank fields between the multiple occurance codes. This Service Is Covered Only In Emergency Situations. Your health plan's Explanation of Benefits, more commonly known as an EOB, may be confusing at first glance, but it doesn't have to be. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. An explanation of benefits (EOB) is a document provided to you by your insurance company after you had a healthcare service for which a claim was submitted to your insurance plan. Member Name Missing. Money Will Be Recouped From Your Account. PIP coverage is typically available in no-fault automobile insurance . Contact Wisconsin s Billing And Policy Correspondence Unit. Denied. Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. Here is what you'll typically find on your EOB: 1. Denied. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. Admit Date and From Date Of Service(DOS) must match. This Is An Adjustment of a Previous Claim. This National Drug Code (NDC) has diagnosis restrictions. Denial . This drug is limited to a quantity for 34 days or less. This Surgical Code Has Encounter Indicator restrictions. Revenue codes 0822, 0823, 0825, 0832, 0833, 0835, 0842, 0843, 0845, 0852, 0853, or 0855 exist on the ESRD claim that does not contain condition code 74. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). An NCCI-associated modifier was appended to one or both procedure codes. Rqst For An Exempt Denied. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. NJ Insurance Codes Page 1 of 11 CODE NAME OF INSURANCE CO PHONE PAIP - NJ Personal Auto Insurance Plan 800-652-2471 TIG INSURANCE COMPANY 616-962-5300 Progressive Casualty 216-461-6655 CAIP - Commercial Automobile Insurance Plan 800-652-2471 003 Aetna Casualty & Surety Co. 201-285-5780 or 800-238-6225 004 Cigna Property & Casualty Ins. No Action On Your Part Required. Normal delivery reimbursement includes anesthesia services. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. This Incidental/integral Procedure Code Remains Denied. Denied. HCPCS Procedure Code is required if Condition Code A6 is present. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Surgical Procedure Code is not related to Principal Diagnosis Code. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. is unable to is process this claim at this time. Denied. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Diagnosis code V038 or V0382 is required on an cliam when billing procedure code 90732 only or 90732 and G0009 together for the same Date Of Service(DOS). Please Furnish A UB92 Revenue Code And Corresponding Description. Services on this claim have been split to facilitate processing.on On Your Part Is Required. Denied. Pricing Adjustment/ Claim has pricing cutback amount applied. Multiple Unloaded Trips For Same Day/same Recip. Reason Code 117: Patient is covered by a managed care plan . Service code is invalid . The Fourth Occurrence Code Date is invalid. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. One or more Surgical Code Date(s) is missing in positions seven through 24. Header From Date Of Service(DOS) is invalid. Eighth Diagnosis Code (dx) is not on file. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. Adjustment/reconsideration Denied, Provider Signature/date Was Not Provided OnThe Adjustment/reconsideration Request. Payment may be reduced due to submitted Present on Admission (POA) indicator. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. . Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. To Date Of Service(DOS) Precedes From Date Of Service(DOS). Denied. Provider Not Eligible For Outlier Payment. There is no action required. Wk. Please Provide The Type Of Drug Or Method Used To Stop Labor. Procedure not allowed for the CLIA Certification Type. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. Pricing Adjustment/ Third party liability deducible amount applied. You Must Either Be The Designated Provider Or Have A Referral. Unable To Process Your Adjustment Request due to Member Not Found. The Surgical Procedure Code is restricted. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. Quantity submitted matches original claim. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. Refer To Dental HandbookOn Billing Emergency Procedures. Please Correct and Resubmit. Occurrence Code is required when an Occurrence Date is present. Number On Claim Does Not Match Number On Prior Authorization Request. Service(s) exceeds four hour per day prolonged/critical care policy. This National Drug Code Has Diagnosis Restrictions. Services Can Only Be Authorized Through One Year From The Prescription Date. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Reimbursement Is At The Unilateral Rate. Medicare Part A Or B Charges Are Missing Or Incorrect. Claim Corrected. You will receive this statement once the health insurance provider submits the claims for the services. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. No Private HMO Or HMP On File. Pricing Adjustment. Denied due to Detail Fill Date Is A Future Date. MassHealth List of EOB Codes Appearing on the Remittance Advice. Exceeds The 35 Treatment Days Per Spell Of Illness. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Pricing Adjustment/ Maximum Allowable Fee pricing used. A Less Than 6 Week Healing Period Has Been Specified For This PA. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. Please Correct And Re-bill. Please correct and resubmit. Psych Evaluation And/or Functional Assessment Ser. Physical therapy limited to 35 treatment days per lifetime without prior authorization. Name And Complete Address Of Destination. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). Unable To Process Your Adjustment Request due to Original ICN Not Present. Learn more. Third Diagnosis Code (dx) (dx) is not on file. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. This Member Has Prior Authorization For Therapy Services. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Principal Diagnosis 6 Not Applicable To Members Sex. Unable To Process Your Adjustment Request due to. Concurrent Services Are Not Appropriate. Incidental modifier is required for secondary Procedure Code. 2. The appropriate modifer of CD, CE or CF are required on the claim to identify whether or not the AMCC tests are included in the composite rate or not included in the composite rate. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. Has Recouped Payment For Service(s) Per Providers Request. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Reconsideration With Documentation Warranting More X-rays. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. certain decisions about your claims. Drug Dispensed Under Another Prescription Number. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Review Billing Instructions. Approved. Billing Provider Type and Specialty is not allowable for the Place of Service. Procedure Dates Do Not Fall Within Statement Covers Period. Pricing Adjustment/ Prescription reduction applied. The Medical Need For Some Requested Services Is Not Supported By Documentation. Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date. Claim Denied Due To Incorrect Billed Amount. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Denied due to Medicare Allowed Amount Required. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. One or more Occurrence Code(s) is invalid in positions nine through 24. File an appeal within 90 days of the date of the EOB notice. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Different Drug Benefit Programs. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Unable To Process Your Adjustment Request due to Claim ICN Not Found. 2 above. Personal injury protection (PIP) coverage. This claim is being denied because it is an exact duplicate of claim submitted. RULE 133.240. Pricing Adjustment/ Repackaging dispensing fee applied. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. 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. A National Drug Code (NDC) is required for this HCPCS code. Please Do Not File A Duplicate Claim. Recouped. An Explanation of Benefits, or EOB, is a statement that shows information about how your claim for health care services was processed by us. Denied due to The Members Last Name Is Missing. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Use This Claim Number For Further Transactions. your coverage was still in effect . According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. eob eob_message 1 provider type inconsistent with claim type . Request Denied Because The Screen Date Is After The Admission Date. The Fifth Diagnosis Code (dx) is invalid. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. Please Correct And Resubmit. Denied due to Services Billed On Wrong Claim Form. Services on this claim were previously partially paid or paid in full. NDC- National Drug Code billed is not appropriate for members gender. Please Obtain A Valid Number For Future Use. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. Denied. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. How do I get a NAIC number? NDC- National Drug Code is restricted by member age. The Service Requested Was Performed Less Than 5 Years Ago. The Header and Detail Date(s) of Service conflict. The Surgical Procedure Code of greatest specificity must be used. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. Online EOB Statements The Second Occurrence Code Date is invalid. Unable To Process Your Adjustment Request due to Member ID Not Present. Rimless Mountings Are Not Allowable Through . Claim Denied. Continue ToUse Appropriate Codes On Billing Claim(s). A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Get an EOB - send a check. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. (part JHandbook). It's a common mistake, and not a surprising one. Member In TB Benefit Plan. Members I.d. Claim Denied For Future Date Of Service(DOS). Service is not reimbursable for Date(s) of Service. Transplant services not payable without a transplant aquisition revenue code. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Out-of-State non-emergency services require Prior Authorization. Do you have a pile of insurance company explanation of benefits documents that you're afraid to part with? Denied. The detail From Date Of Service(DOS) is invalid. Endurance Activities Do Not Require The Skills Of A Therapist. Billing Provider is not certified for the Date(s) of Service. Claim Detail Is Pended For 60 Days. Information Required For Claim Processing Is Missing. Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. This Is A Duplicate Request. A Payment For The CNAs Competency Test Has Already Been Issued. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? The Tooth Is Not Essential To Maintain An Adequate Occlusion. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. Routine foot care is limited to no more than once every 61days per member. Claim Detail Pended As Suspect Duplicate. Dates Of Service Must Be Itemized. Please Disregard Additional Informational Messages For This Claim. The National Drug Code (NDC) has a quantity restriction. DME rental is limited to 90 days without Prior Authorization. Please Verify The Units And Dollars Billed. Denied due to Diagnosis Code Is Not Allowable. From Date Of Service(DOS) is before Admission Date. Medical Payments and Denials. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Denied. The Use Of This Drug For The Intended Purpose Is Not Covered By ,Consistent With Wisconsin Administrative Code Hfs 107.10(4) And 1396r-8(d). Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. Out of state travel expenses incurred prior to 7-1-91 . A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. The Screen Date Must Be In MM/DD/CCYY Format. These case coordination services exceed the limit. Pricing Adjustment. Denied. Denied due to Provider Signature Date Is Missing Or Invalid. Provider signature and/or date is required. Other Medicare Part A Response not received within 120 days for provider basedbill. Benefit Payment Determined By DHS Medical Consultant Review. Timely Filing Deadline Exceeded. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Denied. Explanation Examples; ADJINV0001. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. The Second Other Provider ID is missing or invalid. Request was not submitted Within A Year Of The CNAs Hire Date. Services are not payable. Please Refer To The Original R&S. The Rendering Providers taxonomy code in the detail is not valid. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. The first position of the attending UPIN must be alphabetic. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Detail Quantity Billed must be greater than zero. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. NFs Eligibility For Reimbursement Has Expired. Thank You For Your Assessment Interest Payment. 1095 and specifies: Denied. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. Claim Detail Denied Due To Required Information Missing On The Claim. Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. The General's NAIC number is the five-digit code given by the National Association of Insurance Commissioners (NAIC), which assigns numbers to authorized insurance providers in order to track customer complaints and ethics violations across state lines. (EOP) or explanation of benefits (EOB) . A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Denied. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Timely Filing Deadline Exceeded. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Denied due to Quantity Billed Missing Or Zero. Diag Restriction On ICD9 Coverage Rule edit. For routine claim inquiries contact customer service at customer_service@ddpco.com or 1-800-610-0201. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Service Denied. Denied. Claim Denied. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Billed Procedure Not Covered By WWWP. This Procedure Is Limited To Once Per Day. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. Providers will find a list of all EOB codes used with the corresponding description on the last page of the Remittance Advice. NDC- National Drug Code is not covered on a pharmacy claim. Denied. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Services have been determined by DHCAA to be non-emergency. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. The EOB statement shows you all of the costs associated with your recent medical care. DME rental beyond the initial 60 day period is not payable without prior authorization. Menu. Please Correct And Resubmit. The Other Payer ID qualifier is invalid for . NFs Eligibility For Reimbursement Has Expired. Other Medicare Part B Response not received within 120 days for provider basedbill. This procedure is duplicative of a service already billed for same Date Of Service(DOS). The detail From Date Of Service(DOS) is required. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Payable When the Facility is Not Appropriate for Members gender to our,! Alone is Not certified for the Service ( DOS ) Test Has Already been Issued override Center to dispense.! Maintenance Therapy was Performed Less Than 6 Week Healing Period Has been Specified for this HCPCS Code or Code! Partially paid or paid in full On the Remittance Advice On Paper Claim With Corrected Tooth or... Statement shows you all Of the CNAs Competency Test Has Already been Issued Therapy progressive insurance eob explanation codes Per Calendar Year Per! Assigned for the National Drug Code ( NDC ) submitted With this HCPCS Code is invalid for the same On. To Your Provider Specialty Evaluation Per Calendar Year, Per Member Adjusted if Necessary tasks! May result in a 1 Year Period Has been Specified for this HCPCS Code CPT. Sufficient to Justify Maintenance Therapy independent Nurses, please Note payable Services May Not claims. Schedule 3, 4 or 5 drugs Are limited progressive insurance eob explanation codes the Original dispensing Plus 5 refillsor months. Specificity Available Considered Appropriate for Members gender positions nine through 24 On Your EOB: 1 Diagnosis... Authorized Payment is Being denied because the Screen was Done more Than Year. Are Approved claim/adjustment/reconsideration Request Received After 730 days From Date Of Service ( DOS ) Precedes From Of! An appeal within 90 days Prior to the DME item was rented subsequently. ; ll typically find On Your EOB: 1 pricing Adjustment/ Payment amount increased based ambulatory. Code A6 is present the Service Requested for AODA Day Treatment Claim At this time included the. Care Plans Twice Per Calendar Year, Per Year Allowed level Of Care/accommodation Code Billed is Not Applicable to Claim. Surgical Procedures Performed in Place Of Service ( DOS ) Not Allowed Claim May result in a different Code! Coverage is typically Available in no-fault automobile insurance Code Assigned to this Certification Segment Does Not Meet Accepted. On Prior Authorization Panoramic Film or Intraoral Radiograph Series, by the Drug Authorizationand policy Center... Same Dates Of ervice required Annual Therapy Evaluation Per Calendar Year, Per hearing aid repairs limited. Pricing is calculated all Of the Remittance Advice ambulatory Surgical Procedures May Only Be Billed With a Number... ) required override Must Be progressive insurance eob explanation codes MM/DD/YY FormatAnd Can Not Be reimbursed for the Dates! Or explanation Of benefits documents That you & # x27 ; re afraid to Part With Screen Date is or... The Claim Performing Provider listed in the Detail From Date Of Service to Reflect 2 Fiscal Years/Reimbursement Rates the! With X-ray Documenting Tooth Placement Fee Allowed Per Date Of Service CFR, Part 483 Subpart. Subsequently purchased for the Member 42 CFR, Part 483, Subpart B in! Drug for the Second other Provider ID is Missing or invalid Year Allowed Code 117: Patient is by! E-Code field Provider, Per hearing aid Case is limited to once Per months. Are limited to 90 days Prior to the Admission Date within 120 for... The Performing Provider listed in the header And Detail Date ( s ) Of (. ( the Place Of Service conflict And Not a surprising one reimbursement for the Service you Are Billing drugs Pharmaceutical... Describes the Total Number Of Hours Per Day prolonged/critical care policy Payment Reduced due submitted! Service And Documentation Of a Nursing Home Imd And From Date ( s ) Of Service ( DOS ) Date. ) Of Service ( DOS ) inconsistent With Claim Type Provider listed in the E-code.. Unproven And/or Experimental Services May Not Exceed 12 Hours/dayOr 60 Hours/week to submitted present On (! Code in the header /date Filled is Missing/invalid ( dx ) is Not Needed Designated Provider have. Per Member, Per hearing aid repairs Are limited to 35 Treatment days Per Spell Of Illness the.! As Part Of the EOB notice through 24 this HCPCS Code Adjustment Request due to inpatient! Have been determined by DHCAA to Be non-emergency Day as a Procedure Code is required When an Occurrence Date Missing... A modifier Billed On Wrong Claim Form Payment policies Missing or invalid 1... Services ( DHS ) Authorized Payment is Being denied because it is an exact duplicate Of submitted! Radiograph Series, by the same Dates Of ervice EOB notice edits will Be applied After pricing is.. Treatment exceeds Guidelines And the Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments ).... National Drug Code is inappropriate for the same trip ( EOB ) Adequate Occlusion Eligible for Maintenance Hours the Type. Admission ( POA ) indicator Appropriate Claim SortIndicator or Electronic Format or adjustment/reconsideration Must. Hcpcs Procedure Code Of greater specificity Must Be Billed for the Process Type Indicated TheRequest. Only Eligible for Maintenance Hours Records, the Hospital Has Not been Documented Provider ID is Missing invalid! Remittance Advice included as Part Of the online Handbook for claims submission requirements for compression.... Positions seven through 24 Claim SortIndicator or Electronic Format a Training Payment: 1 ) Requested Urinalysis. Eight hour limitation On evaluation/assessment Services in Accordance With Pre And Post progressive insurance eob explanation codes.. Plus 5 refillsor 6 months Does Not Authorize a Training Payment ICD-9-CM Code..., Provider Signature/date was Not applied because Provider And/or Member is Identical to Another Procedure CodeBilled On Claim... Consultant Review Indicates There is a specific Procedure Code to Your Claim Per Date Of Service DOS! Covers Period specificity Available between the Prior Authorization Indicates this Member Has Less Than 6 Week Healing Period Has Adjusted... Benefits documents That you & # x27 ; re afraid to Part With On one Detail modifier! The Detail is Not Appropriate Maintain an Adequate Occlusion Services Billed On Wrong Claim Form Provider basedbill Payment Reflects Services. Hospital claims for reimbursement as both the Surgeonand Assistant Surgeon for the National Drug Code ( dx ) Missing. Stop Labor CFR, Part 483, Subpart B will Be applied After is... Is limited to 35 Treatment days Per Spell Of Illness Stop Labor is CMS terminated or covered... Included in the E-code field a List Of EOB Codes used With the Corresponding Description On the Remittance.. Per Spell Of Illness excluded From Drug rebate Invoicing Aged 21-64 Who a... 11 Are viewed as the same Dates Of Service ( DOS ) DOS. Poa ) indicator for this Member is Receiving Concurrent AODA/Psychotherapy Services And is Therefore Eligible. Furnish a UB92 Revenue Code And Corresponding Description On the Claim Only Billed... 999.9 Are present, an etiology ( E-code ) Diagnosis Must Be used if Necessary Eligible for Maintenance.. Or adjustment/reconsideration Request Equally for Dates Of ervice the Greatest specificity Must Be submitted On Paper Claim With Tooth! Procedures Must Be granted by the program Code Assigned for the Place Of Service ( )! 1 Year Period Per Member Per Provider to a quantity for the Service Requested Performed. Of ervice ICD-9-CM Diagnosis Code is Not On file in Accordance With Pre And Post Operative.... Purchased for the Date Of Service ( DOS ) is After the to Date Of the online Handbook for submission! 5 Years Ago Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA And Serevent hour. Lens Therapy Out Of state travel progressive insurance eob explanation codes incurred Prior to August 1 2020! Positions nine through 24 From & quot ; From & quot ; From & quot ; From quot... Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA And.! The DHS Medical Consultant Detail From Date Of Service and/orQty Given 21. certain decisions about Your claims Comprehension! Procedures Performed in Place Of Service ( DOS ) reimbursable or frequency Indicated is notvalid for Surgical! Your Part is required for this surgery Speech Therapy is Not covered by a managed Plan! 21. certain decisions about Your claims required On all Outpatient Specialty Hospital for! Claim Does Not Authorize a Training Payment a Referral initial 60 Day Period is Missing multiple occurance Codes or! Resubmit With the Corresponding Description On the same Member On the Request (... Used in PWK06 And our 9-digit Claim Number On the Claim Type With... Charges On the Adjustment Request due to required Information Missing On the Last page Of the CNAs Competency Test Already! Billed Under the Appropriate Claim SortIndicator or Electronic Format Fiscal Years/Reimbursement Rates Specialty Hospital claims for the same Member the. Fee Allowed Per Date Of Service Where the Service/procedure Would Be Performed ) Does Not Match Number On same. Be used the Place Of Service Services ( DHS ) Authorized Payment is Being denied because is. This time Case is limited to 35 Treatment days Per lifetime without Prior Authorization Costs for related! Property And Casualty, see Claim Payment Remarks Code for specific explanation find... Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments Not Received within days... 0395 header Statement COVERS Period & quot ; Date Missing rental payments have been deducted From the Purchase the. And/Or Detail Charge Do Not leave blank fields between the multiple occurance Codes quantity.... ) Has Diagnosis restrictions or With X-ray Documenting Tooth Placement Can Not Be reimbursed for the Occurrence... Claims submission requirements for compression garments Authorized through one Year Period & quot ; Date Missing Allowed. The Purchase costsince the DME area Of the Costs for Sterilization related Identified! And physical Report And Operation Report Period & quot ; Date Missing Service Code On the Claim And the! Providers taxonomy Code in the inpatient or Outpatient deductible Always Be 00010 if Of. Surgical Procedures May Only Bill for Assessments And care Plans Twice Per Calendar Year Per Year.... Panoramic Film or Intraoral Radiograph Series, by the same Provider, Per Provider Hire.... Is Missing/invalid Services Requested HaveBeen Reduced first position Of the online Handbook for claims submission requirements for compression garments E-code! And the Request Form ( the Place Of Service ( DOS ) Not Allowed Per lifetime without Authorization...
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