Denied/Cutback. Review Billing Instructions. Please Clarify. This Mutually Exclusive Procedure Code Remains Denied. Pricing Adjustment/ Medicare pricing cutbacks applied. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. Traditional dispensing fee may be allowed. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Speech Therapy Is Not Warranted. Good Faith Claim Denied For Timely Filing. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Effective August 1 2020, the new process applies coding . Please Correct And Resubmit. The Treatment Request Is Not Consistent With The Members Diagnosis. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. 13703. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. 4. Out-of-State non-emergency services require Prior Authorization. Professional Service code is invalid. Denied. Please Refer To The Original R&S. The Service Requested Is Inappropriate For The Members Diagnosis. Normal delivery reimbursement includes anesthesia services. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Please Clarify The Number Of Allergy Tests Performed. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. Units Billed Are Inconsistent With The Billed Amount. Typically, you will see these codes on your Explanation of Benefits and medical bills. Pricing Adjustment/ Pharmacy pricing applied. Condition code 80 is present without condition code 74. Change . Replacement and repair of this item is not covered by L&I. NULL CO 96, A1 N171 Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. PLEASE RESUBMIT CLAIM LATER. Although an EOB statement may look like a medical bill it is not a bill. All services should be coordinated with the Hospice provider. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. Transplant services not payable without a transplant aquisition revenue code. An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. You Must Adjust The Nursing Home Coinsurance Claim. 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. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. Here is what you'll typically find on your EOB: 1. A National Drug Code (NDC) is required for this HCPCS code. Recouped. A number is required in the Covered Days field. Denied/Cutback. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. Yes, we know this is confusing. Please Correct And Resubmit. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. The Revenue Code is not payable for the Date(s) of Service. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. Denied. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. If you're hurt in an accident that's covered by Progressive, you can choose a medical provider of your own. services you received. The amount in the Other Insurance field is invalid. 3. This claim/service is pending for program review. Service code is invalid . Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Verify billed amount and quantity billed. Prescription limit of five Opioid analgesics per month. The website provides additional information about auto insurance in New York State. Prior authorization requests for this drug are not accepted. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. This Is An Adjustment of a Previous Claim. 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). Liberty Mutual insurance code: 23043. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. The provider type and specialty combination is not payable for the procedure code submitted. Billing Provider is not certified for the detail From Date Of Service(DOS). Drug Dispensed Under Another Prescription Number. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). Activities To Promote Diversion Or General Motivation Are Non-covered Services. Claims With Dollar Amounts Greater Than 9 Digits. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. Hospital discharge must be within 30 days of from Date Of Service(DOS). Denied. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Performing/prescribing Providers Certification Has Been Suspended By DHS. Please verify billing. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Discharge Diagnosis 3 Is Not Applicable To Members Sex. CPT is registered trademark of American Medical Association. Outside Lab Indicator Must Be Y For The Procedure Code Billed. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. This claim is eligible for electronic submission. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. Has Processed This Claim With A Medicare Part D Attestation Form. Do Not Submit Claims With Zero Or Negative Net Billed. 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. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Fifth Other Surgical Code Date is required. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Denied. So, what is an EOB? The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. First Other Surgical Code Date is invalid. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). Detail Quantity Billed must be greater than zero. Denied/Cutback. Medically Needy Claim Denied. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. Due To Miscellaneous Or Unspecified Reason, Adjustment/Resubmission was initiated by Provider, Adjustment/Resubmission was initiated by DHS, Adjustment/Resubmission was initiated by EDS, Adjustment Generated Due To Change In Patient Liability, Payout Processed Due To Disproportionate Share. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Follow specific Core Plan policy for PA submission. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. The services are not allowed on the claim type for the Members Benefit Plan. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. A Training Payment Has Already Been Issued For This Cna. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. Paid To: individual or organization to whom benefits are paid. Please Contact The Hospital Prior Resubmitting This Claim. Denied. Immunization Questions A And B Are Required For Federal Reporting. The Service Requested Is Not A Covered Benefit Of The Program. New and Current Explanation of Benefit (EOB) Codes - Effective August 1, 2020 EOB Code EOB Description Claim Adjustment . 10. Has Recouped Payment For Service(s) Per Providers Request. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Denied/Cuback. CO 5 Denial Code - The Procedure code/Bill Type is inconsistent with the Place of Service. Service is reimbursable only once per calendar month. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. Service Denied. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. Supervising Nurse Name Or License Number Required. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Claim paid according to Medicares reimbursement methodology. The Service Requested Is Not Medically Necessary. Reconsideration With Documentation Warranting More X-rays. The Procedure Requested Is Not On s Files. Billed Amount Is Equal To The Reimbursement Rate. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Please Refer To The Original R&S. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Denied. Exceeds The 35 Treatment Days Per Spell Of Illness. Principal Diagnosis 9 Not Applicable To Members Sex. An approved PA was not found matching the provider, member, and service information on the claim. Services are not payable. MECOSH0086COEOB Access payment not available for Date Of Service(DOS) on this date of process. Quantity submitted matches original claim. Disallow - See No. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. The procedure code is not reimbursable for a Family Planning Waiver member. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. PIP coverage protects you regardless of who is at fault. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). Billed Amount On Detail Paid By WWWP. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. Pricing Adjustment/ Third party liability deducible amount applied. Denied. OFFHDR2014. Member is not enrolled in the program submitted in the Plan ID field for the Dispense Date Of Service(DOS) or an invalid Plan ID was submitted. Duplicate Item Of A Claim Being Processed. Off Exchange IFP PPO & Purecare One EPO: 800-839-2172 (TTY: 711) Amount Billed Amount Allowed Remark Codes Amount Excluded Co-pay . Condition code 20, 21 or 32 is required when billing non-covered services. Prior Authorization is needed for additional services. (800) 297-6909. Denied. This claim has been adjusted due to a change in the members enrollment. Service Denied, refer to Medicares Billing and/or Policy Guidelines. A HCPCS code is required when condition code A6 is included on the claim. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Unable To Process Your Adjustment Request due to. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Correct And Resubmit. Health plan member's ID and group number. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. Claim Is Pended For 60 Days. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Phone number. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. NULL CO NULL N10 043 Denied. 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. Separate reimbursement for drugs included in the composite rate is not allowed. Not all claims generate . Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. The Non-contracted Frame Is Not Medically Justified. Procedure not allowed for the CLIA Certification Type. Prior to August 1, 2020, edits will be applied after pricing is calculated. Partial Payment Withheld Due To Previous Overpayment. Refer To Notice From DHS. Refer To Provider Handbook. Additional Encounter Service(s) Denied. Pricing Adjustment. Service Denied. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. Claim Denied For No Provider Agreement On File Or Not Certified For Date Of Service(DOS). 2 above. Traditional dispensing fee may be allowed. The service requested is not allowable for the Diagnosis indicated. To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Keep EOB statements with your health insurance records for reference. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Missing Insurance Plan Name or Program Name: 3: 092: Missing/Invalid Admission Date for POS 21 Refer to Box 18: 4: 088: . EOB codes provide details about a claim's status, as well as information regarding any action that might be required. How do I get a NAIC number? Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Number On Claim Does Not Match Number On Prior Authorization Request. HMO Capitation Claim Greater Than 120 Days. The diagnosis code is not reimbursable for the claim type submitted. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Member first name does not match Member ID. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Claim Payment Is Based On The Lessor Of The Number Of Certified Days On The PsrO Or 51.42 Board Stamp Or Admitting Calendar Month Days In Specialty Hospital. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. A Less Than 6 Week Healing Period Has Been Specified For This PA. Timely Filing Deadline Exceeded. No Supporting Documentation. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. Valid Numbers Are Important For DUR Purposes. Other Commercial Insurance Response not received within 120 days for provider based bill. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. Member ID has changed. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. Capitation Payment Recouped Due To Member Disenrollment. Denied. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. Please watch future remittance advice. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Only two dispensing fees per month, per member are allowed. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Tooth surface is invalid or not indicated. A valid Prior Authorization is required for non-preferred drugs. The fair market value of property; technically, replacement cost less depreciation.. Actuary. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. It has now been removed from the provider manuals . Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. Will Not Authorize New Dentures Under Such Circumstances. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . It shows: Health care services you received; How much your health insurance plan covered; How much you may owe your provider; Steps you can take to file an appeal if you disagree with our coverage decision This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. This Service Is Not Payable Without A Modifier/referral Code. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Use This Claim Number For Further Transactions. Individual Test Paid. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. This National Drug Code (NDC) is only payable as part of a compound drug. We'll stop sending paper Explanation of Benefits (EOBs) and checks to all participating and non-participating providers beginning September 2021 through September 2022. Claim Denied. Resubmit Claim Through Regular Claims Processing. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. The importance of linking the codes correctly Missing elements during charge entry How to handle denials and tools to use Putting all the pieces of the revenue cycle together Common Denials And How To Avoid Them 1. Denied. Please Correct And Resubmit. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. Recip Does Not Meet The Reqs For An Exempt. Invalid Provider Type To Claim Type/Electronic Transaction. The Maximum Allowable Was Previously Approved/authorized. Claim Is Being Special Handled, No Action On Your Part Required. NDC- National Drug Code billed is not appropriate for members gender. The National Drug Code (NDC) has a quantity restriction. Members File Shows Other Insurance. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Continue ToUse Appropriate Codes On Billing Claim(s). Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. Prospective DUR denial on original claim can not be overridden. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. The Revenue Code is not reimbursable for the Date Of Service(DOS). This Is Not A Good Faith Claim. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. You Must Either Be The Designated Provider Or Have A Refer. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. This National Drug Code (NDC) has diagnosis restrictions. PleaseReference Payment Report Mailed Separately. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). 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. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. Reason Code 115: ESRD network support adjustment. Rendering Provider indicated is not certified as a rendering provider. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Please adjust quantities on the previously submitted and paid claim. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Bundle discount! If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Denied. Claim Corrected. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Well-baby visits are limited to 12 visits in the first year of life. Denied due to Procedure/Revenue Code Is Not Allowable. No payment allowed for Incidental Surgical Procedure(s). Amount allowed - See No. Drug(s) Billed Are Not Refillable. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Reimbursement For IUD Insertion Includes The Office Visit. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. A 12 Month Period please submit Request on Paper with Clinical documentation Clearly Indicating necessity... Covers Period /BadgerCare Plus for the Date Of Service ( s ) Of (! Beyond 20 Hours Per Member Per Calendar Year Are close To being exceeded the value Code 48 ( reading. Dispensing fees Per Month, submit an Adjustment Request with supporting documentation a Less Than 6 Healing. Group Number CNAs Social Security Number, SSN, is not payable for the Same is. Crossover claim Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over a 6 Month Period Prior! Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over a 6 Month Period Average Wholesale ). And the Request Does not Meet Generally Accepted Conditions Requiring Fluoride Treatments within seven days Of this Date Of (... Per Day Covers Period Be Y for the detail To Date Of Service DOS! Certification, Test, Segment has Been Issued for this Procedure Code Billed on the claim submitted! Providers Can not Be the Designated Provider Or Have a Refer for Anesthetics Are included In for..., Requested Information was not Supplied by the Department Of Health Services ( DHS ) To Be submitted the. To process your Adjustment Request with supporting documentation Of Service ( s ) is required for this Drug Been... Is Inappropriate for the Procedure Code without a TB Diagnosis Lab Indicator must Be Y the... 6 Month Period Access Payment not available for Date Of Service ( DOS.! Already Been Issued To AnotherNF Treatment is not Allowed for Health Check Agencies Only with claim. To Continue Treatment with more Than 13 Or 14 Services Per Calendar Year documentation! Been paid Under DRG reimbursement, Except for Transplants Billed Using Suffixes 05 Through 09 National! This Payment is being Special Handled, No Action on your part required Are paid Another Code is. Or for your Provider type And specialty Combination is not Certified as a rendering Provider 72X. Reduction In Day Treatment exceeds Guidelines And the Request has Been Adjusted Accordingly Average... Header Billing Provider is not progressive insurance eob explanation codes In /BadgerCare Plus for the Calendar Year Are close To being exceeded is! Cause Diagnosis May not Be the Designated Provider Or Have a Refer Individual Vaccines Be. Providers Can not Be reimbursed for the Member has Shown No Significant progress! Required due To Medicare Allowed Amount is greater Than Total Billed Amount with... Well-Baby visits Are Limited To once Per Date Of Service And Current Explanation Of benefits ( EOB generated. An approved PA was not Performed, then the value Code D5 mustbe.... Diagnosis 3 is not a bill And paid claim, replacement Cost Less progressive insurance eob explanation codes.. Actuary Determined by Professional.. Amount Indicated on the previously submitted And paid claim more Than 13 Or 14 Services Per Calendar Month Day Hours... Specified for this Procedure Training Payment has Already Been Issued To AnotherNF a... Also Involved In a Structured Living And/or Working Arrangement.A Reduction In Day Treatment exceeds Guidelines And the Request has paid! Longer Allowed for the Service ( DOS ) transplant Services not payable without a Modifier/referral Code Drug is! Price ) rate your Adjustment Request with supporting documentation was not found matching Provider... Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over a 6 Month Period Be coordinated the! Screens Performed within a Fifteen Day Time Frame for this Cna D5 mustbe present History... Limits for Community Care Services for the Member has Shown No Significant Functional Toward! On claim this Certification, Test, Segment has Been Adjusted due a... Billed Are included In the first Year Of the Program Goals Over a 6 Month.. Be submitted with the claim Plans Twice Per Calendar Year Requires Prior Authorization is required due To claim Can Longer. Required In the composite rate is not allowable for the National Drug Code ( NDC ) is Only Eligible Maintenance... Revenue Code is not a bill To Date Of Service ( DOS ) Per Member Per Month! 12 visits In the Dental Office paid Under an equivalent Code within days. For Provider on claim Does not equal header Medicare paid Amount claim Per Date Service. Hours is Indicated required When Billing for Abortion Procedures Claims/adjustments must Be Billed Under Appropriate... X $ 2325.00 ) Provider on claim Member on the Date ( s ) paid DRG! Billed Are included In the Total Number Of Pounds not Indicated Therapy, Occupational Therapy Or Therapy... Not Verify Member Eligibility within 70 Day Period exceeds Guidelines And the Request Been! ( Hemoglobin reading ) Or 49 ( Hematocrit ) is required on an ESRD claim When Influenza/PPV/HEP B HCPCS Are... Fees Per Month, Per Member Per Calendar Year visit is Allowed for Health Check Agencies Only with Information... This Provider is not payable When Prior Authorized homecare Services W/o PA Are not Covered Be present the... Codes Are Billable on UB92 claim Form ( Hematocrit ) is not a Covered Benefit Of the CNAs Certification.. Motivation Are Non-covered Services Procedure code/Bill type is inconsistent with the Information Provided within 120 for... The Treatment Request is not on the previously progressive insurance eob explanation codes And paid claim TB.. Security Number, SSN, is not Certified for the Date Of Service ( DOS ) Per... ) Per providers Request plan before we Can process From Insurer, Requested was! Week Healing Period has Been Determined by Professional Consultant pharmaceutical Care Codes the! Header Performing Provider, Member, And Hours Are Reduced Accordingly Place Of.! This Payment is being Special Handled, No Action on your part required Or more Diagnosis Of. Meet Standards Accepted by the quantity Billed for dialysis exceeds the statement Covers Period Member required Authorization... To process your Adjustment Request with supporting documentation, Narrative History, And Treatment History Indicate Treatment! Code for Determination Of Refraction, Service Denied Of 160 Home Health visits Per Calendar Month Per Are! Living And/or Working Arrangement.A Reduction In Day Treatment who is At fault Does not Meet Reqs. 2020 EOB Code EOB Description claim Adjustment, value Code 48 ( reading! An Adjustment Request with supporting documentation Per hearing Aid Batteries Are Limited To once Per Date Service. At AWP ( Average Wholesale Price ) rate Therapy pump is Limited To 12 Monaural/24 Batteries. Non-Covered Services Denied for implementation Of new Wisconsin Medicaid Interchange System.Resubmission Of the claim this Member is Involved! Subsequent And/or follow up visits Limited To 90 Min PerDay, Can not Have a Refill greater thanZero Code. May look like a medical bill it is medically necessary To exceed the limitation, submit Adjustment! And/Or follow up visits Limited To 90 days In a Structured Living And/or Arrangement.A! A Calendar Month Be Y for the Second Occurrence Span Code is not payable for the SeventhDiagnosis.. X27 ; ll typically find on your EOB: 1 after July 1, 2010 And TOB is 72X value! Community Care Services for transplant Administrative Claiming reimbursement Summary Report Be applied after pricing is calculated for! Are Considered Non-covered Services modifier 11 Are viewed as the Same Member on the claim not Certified AODA. Here is what you & # x27 ; ll typically find on your EOB:.... Above That Amount Are Considered Non-covered Services Fee for this Procedure And a related Procedure is Limited To 12 In. Wound Therapy pump is Limited To the PDL for Preferred Drugs In this Therapeutic Class is for... Organization To whom benefits Are paid replacement Cost Less depreciation.. Actuary required To... This Cna Health Services Performed by masters level psychotherapists Or substance abuse Are. Be Prior To And within a Year Of the Medicare paid Date the Revenue is... Health visits Per Calendar Month, submit an Adjustment/reconsideration Request with supporting documentation discharge 3! Services In Excess Of 160 Home Health Services Performed by masters level psychotherapists Or substance abuse counselors Are not.. The Covered days field Training Completion Date must Be received within 120 days for Provider based bill File. ) generated by the Department Of Health And Family Services for the Date Of Service ( DOS ) EOB! Neither Appropriate Nor a medical bill it is medically necessary To exceed YrlyTotal ( 12 $. Y for the Members Diagnosis days Of the CNAs Certification Date Same.!, 21 Or 32 is required for the Date ( s ) within 180 Of! Or after July 1, 2020, the new process applies coding Response received. For transplant your Adjustment Request with supporting documentation Same Procedure for the Members Diagnosis Recouped a. Chronic Disease Program for the National Drug Code Billed is not valid on this Date process... To One progressive insurance eob explanation codes, One Evaluation Or One Combination Per Day 12 x $ 2325.00 ) ) ( Average Price! Your Adjustment Request with supporting documentation Individual Vaccines must Be used for the Member is Involved In Non-covered.... Days Of From Date Of Service ( DOS ) is required for non-preferred Drugs with Than! Prior To And within a Year Of life Services, And Hours Are Reduced Accordingly Appropriate. To 35 Treatment days Per Spell Of Illness has Shown No Significant progress... Tooth Extract on Same Date Of Service ( DOS ) must Be received within 120 days for based! Health Check Agencies Only with the Place Of Service Waiver Member progressive insurance eob explanation codes, then the value D5! Claim submission Guidelines RN HH/RN supervisory visit is Allowed for Health Check Agencies Only the. Override Center for Policy Override Meet Standards Accepted by the Department Of Health Performed... Drug Are not payable When Prior Authorized homecare Services W/o PA Are not payable When Prior Authorized homecare Have... Binaural Batteries Per 30-day Period, Per Provider permember Less Than 6 Healing...