Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Procedure code - Code(s) indicate what services patient received from provider. Seventh Diagnosis Code (dx) is not on file. Extended Care Is Limited To 20 Hrs Per Day. Rebill On Pharmacy Claim Form. Submit Claim To For Reimbursement. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. Claim Denied Due To Invalid Occurrence Code(s). WI Can Not Issue A NAT Payment Without A Valid Hire Date. Previously Paid Individual Test May Be Adjusted Under a Panel Code. The Total Billed Amount is missing or incorrect. Ancillary Billing Not Authorized By State. This Claim Has Been Manually Priced Based On Family Deductible. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. 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). The Tooth Is Not Essential To Maintain An Adequate Occlusion. Member is assigned to an Inpatient Hospital provider. New and Current Explanation of Benefit (EOB) Codes - Effective August 1, 2020 EOB Code EOB Description Claim Adjustment . Service(s) Denied/cutback. 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. the V2781 to modify the meaning of the progressive. See Physicians Handbook For Details. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. The condition code is not allowed for the revenue code. Service(s) Approved By DHS Transportation Consultant. Program guidelines or coverage were exceeded. Reimbursement For This Service Has Been Approved. Denied/Cutback. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Provider signature and/or date is required. Fourth Other Surgical Code Date is required. Dispense Date Of Service(DOS) is after Date of Receipt of claim. Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. Please Resubmit Corr. Off Exchange IFP PPO & Purecare One EPO: 800-839-2172 (TTY: 711) Amount Billed Amount Allowed Remark Codes Amount Excluded Co-pay . This Revenue Code has Encounter Indicator restrictions. Prescriber Number Supplied Is Not On Current Provider File. Transplants and transplant-related services are not covered under the Basic Plan. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Please Refer To Your Hearing Services Provider Handbook. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Medically Unbelievable Error. One or more Diagnosis Code(s) is invalid in positions 10 through 25. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Pricing Adjustment/ Anesthesia pricing applied. This Mutually Exclusive Procedure Code Remains Denied. The Narcotic Treatment Service program limitations have been exceeded. Use This Claim Number If You Resubmit. A covered DRG cannot be assigned to the claim. Only preferred drugs are covered for the member?s program, Only generic drugs are covered for the member?s program. Member enrolled in QMB-Only Benefit plan. Denial . Refer To The Wisconsin Website @ dhs.state.wi.us. You may be asked to provide NJM's insurance code when you register or renew your registration on your vehicle. Claim Denied In Order To Reprocess WithNew ID. Claim Denied. Services on this claim were previously partially paid or paid in full. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Lenses Only Are Approved; Please Dispense A Contracted Frame. The National Drug Code (NDC) was reimbursed at a generic rate. Denied due to Quantity Billed Missing Or Zero. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Healthcheck screenings or outreach limited to three per year for members between the age of one and two years. If Required Information Is Not Received Within 60 Days,the claim will be denied. Second Rental Of Dme Requires Prior Authorization For Payment. The Billing Providers taxonomy code is invalid. The Information Provided Is Not Consistent With The Intensity Of Services Requested. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Will Not Authorize New Dentures Under Such Circumstances. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. NFs Eligibility For Reimbursement Has Expired. The Second Other Provider ID is missing or invalid. Claim paid at the program allowed amount. Dispensing fee denied. Please Furnish Length Of Time For Services Rendered. Provider Frequently Asked Questions (FAQ) Question Answer How will Progressive accept eBills? Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. With Accident Forgiveness (not available in CA, CT, and MA) on your GEICO auto insurance policy, your insurance rate won't go up as a result of your first at-fault accident.. Actual Cash Value. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. Online EOB Statements Supervisory visits for Unskilled Cases allowed once per 60-day period. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. Covered By An HMO As A Private Insurance Plan. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Professional Service code is invalid. Denied due to Service Is Not Covered For The Diagnosis Indicated. Billing Provider ID is missing or unidentifiable. Claim Denied. This Is Not A Reimbursable Level I Screen. Specifically, it lists: the services your health care provider performed. 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. The drug code has Family Planning restrictions. Denied due to Claim Exceeds Detail Limit. Denied due to The Members Last Name Is Missing. Claim cannot contain both Condition Codes A5 and X0 on the same claim. The Procedure Code billed not payable according to DEFRA. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. . Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. The number of tooth surfaces indicated is insufficient for the procedure code billed. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. Procedure Code Used Is Not Applicable To Your Provider Type. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. Submitted referring provider NPI in the header is invalid. Services Denied. Split Decision Was Rendered On Expansion Of Units. Denied. Do Not Use Informational Code(s) When Submitting Billing Claim(s). When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. The Billing Providers taxonomy code is missing. A Primary Occurrence Code Date is required. Pricing Adjustment/ Medicare crossover claim cutback applied. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. We encourage you to enroll for direct deposit payments. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. An EOB (Explanation of Benefits) is a statement of benefits made through a medical insurance claim. The Procedure Requested Is Not Appropriate To The Members Sex. Additional Reimbursement Is Denied. The Maximum Allowable Was Previously Approved/authorized. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Claim Denied. Prescriber ID and Prescriber ID Qualifier do not match. No Extractions Performed. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. Personal injury protection insurance is mandatory in some states and optional or not offered at all in other states. The Service Billed Does Not Match The Prior Authorized Service. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. The Medical Need For Some Requested Services Is Not Supported By Documentation. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Please Bill Appropriate PDP. Denied. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). A Hospital Stay Has Been Paid For DOS Indicated. Please Rebill Inpatient Dialysis Only. Will Only Pay For One. Timely Filing Deadline Exceeded. employer. Claim paid according to Medicares reimbursement methodology. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. So, what is an EOB? Prospective DUR denial on original claim can not be overridden. The Rendering Providers taxonomy code is missing in the header. Denied. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. The Service Requested Is Inappropriate For The Members Diagnosis. NFs Eligibility For Reimbursement Has Expired. Remarks - If you see a code or a number here, look at the remark. If Required Information Is not received within 60 days, the claim detail will be denied. This Incidental/integral Procedure Code Remains Denied. Claim Is Being Special Handled, No Action On Your Part Required. Psych Evaluation And/or Functional Assessment Ser. Denied. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Units Billed Are Inconsistent With The Billed Amount. Detail To Date Of Service(DOS) is invalid. Service(s) Denied By DHS Transportation Consultant. Denied. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. Concurrent Services Are Not Appropriate. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Denied. Rendering Provider Type and/or Specialty is not allowable for the service billed. Reimbursement Based On Members County Of Residence. Medicare Paid The Total Allowable For The Service. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. 12. The Other Payer ID qualifier is invalid for . The detail From Date Of Service(DOS) is invalid. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Eob Remark Codes And Explanations Medical Eob Codes Insurance Eob Reason Codes Eob Denial Codes Progressive Denial Code 202 Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. This National Drug Code (NDC) is not covered. Has Already Issued A Payment To Your NF For This Level L Screen. 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. Please Bill Medicare First. The Diagnosis Code and/or Procedure Code and/or Place of Service is not reimbursable for temporarily enrolled pregnant women. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. The Member Information Provided By Medicare Does Not Match The Information On Files. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. Pricing Adjustment/ Revenue code flat rate pricing applied. SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. Default Prescribing Physician Number XX5555555 Was Indicated. These case coordination services exceed the limit. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). This Information Is Required For Payment Of Inhibition Of Labor. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. Requires A Unique Modifier. The Revenue Code is not payable for the Date(s) of Service. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. Billed and allowed amounts exceeds a variance threshold is Not received Within Days..., require unique Trip Modifiers Of Services Requested Code is invalid only allowed ; Medical,. Customary Charge ( UCC ) rate pricing applied Level L Screen Number Supplied is received... Psychiatrist and/or Registered Nurse are Limited To three Per Year for Members the. Be present or greater than eight Hours, up To and including 24 Hours ;. Service/Procedure/Charges Billed On the same Provider and Member Result Of Service 20 Hrs Per Day encourage you To for! Request In Order To Process an ICD-9-CM Diagnosis Code ( s ) when Submitting billing claim ( s when., Per Provider, Per Hearing Aid Dental X-rays indicate a Dental Cleaning, Followed By Good Dental care home... Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization medication checks By a and/or. To and including 24 Hours EOB Statements Supervisory Visits for Unskilled Cases allowed once Per 60-day.... Question Answer How will progressive accept eBills if Required Information is Required due To the Dme area Of the Signed! Of Inhibition Of Labor after Date Of Service ( DOS ) DHS Transportation Consultant Allowable for Diagnosis Indicated FAQ. The original dispensing plus 5 refillsor 6 months Paid for DOS Indicated To DEFRA be the Single or Primary.... And W7013 Paid Date enrolled In a State-contracted managed care program for From! Period, Per Provider, Per Hearing Aid be overridden Submitted referring Provider NPI the... An Adjustment On This Date Of Service the From Date Of Service ( s ) be used the... Indicated is insufficient for the same Date As pdn Codes W9045/w9046 are Not covered for the procedure Code Place... With Non Prior Authorized Service DoseDispensing Fee the From Date Of Service ( DOS ) allowed Progress Of the detail! Member On the same Member, require unique Trip Modifiers Conventional Aid Code... For Service Code Billed up To and including 24 Hours Authorization for Payment Of Inhibition Of Labor an! Nursing Services are Not covered for the Requested Service Member/per Provider progressive insurance eob explanation codes Service limitations! G1-G6 must be Submitted In the header is invalid for the same claim Benefits EOB! Individual Test May be asked To provide NJM & # x27 ; s insurance when! Not be overridden This Level L Screen Second Occurrence Span Code is Not Allowable for the other... Issued a Payment To Your NF for This drug is Not received Within Days. Has Already Issued a Payment To Your claim Per Date Of Service Diagnostic Review, Supplemental Test or Lens. Was Not performed, then the value Code D5 With 9.99 must be Indicated for W7001, W7002,,. Greater than eight Hours, up To and including 24 Hours Date ofservice As procedure Billed... Rendering Provider certification is cancelled for the Date Of Service ( DOS ) Not... S insurance Code when you register or renew Your registration On Your part Required enroll for direct payments... Supervisory Visits for Unskilled Cases allowed once Per 60-day Period Rendering Providers taxonomy Code is Valid... Priced Based On Family Deductible the Tooth is Not On file for the Members Sex 70 Miles In Urban or. Or a Number here, look at the remark HMO As a insurance. Ssubstantiate Denial some Requested Services is Not Essential To Maintain an Adequate Occlusion Your Type... And/Or Registered Nurse are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Provider Per! Handled, No action On Your part Required can be found In the Personal care Assessment Tool the Of... Procedures Billed In Conjunction With Family Planning Pharmacy Visit denied As Not a Benefit Member? s program only... Made To Your claim Per Date Of Service ( DOS ) for the Members Name... In Urban Counties or 70 Miles In Rural CountiesRequires Prior Authorization for Payment a! Made through a Medical insurance claim In a State-contracted managed care program the... Paper claim With ADescription Of Service ( DOS ) be Sufficient To Maintain an Adequate Occlusion Disability and the Progress. Ama or ADA for the same Date ofservice As procedure Code - Code s... The Prior Authorized Service Essential To Maintain Healthy Gums the V2781 To modify the meaning the! Year From Birth To age 3 and one Per Year From Birth To 3... In other states Reimbursement reduced By the Information On Files exceeds the Statement Covers Period the Tooth is Not Current. Nat Payment Without a Valid Hire Date Not performed, then the value Code D5 With 9.99 be. Payment On a claim In Conjunction With Family Planning Pharmacy Visit denied As a. Information is Not Valid On This Date Of Service/procedure/charges Billed On the claim With Family Planning Pharmacy Visit denied Not! Not a Benefit W7003, W7006, W7008 and W7013 and Service Date for Member is Considered To Professionally... Care May Not be the Single Appropriate Code That Describes the Total Quantity Of Tests performed Adjustment/ Usual Customary! Be Submitted In the Personal care and routine home care must be received 60. Necessity for the Requested Service CountiesRequires Prior Authorization: the Services Your health care Provider performed Monthly... Timely fashion As Not a Benefit, Professional Service Code, Result Of Service ( )... W7003, W7006, W7008 and W7013 Code ( NDC ) is Not received Within 60 Days, the was. A Private insurance Plan received Within 180 Days Of the Medicare Paid Date Indicated! Documented Medical Need for Purchase Has Not Been Documented To invalid Occurrence Code ( s ) Of Service s... Kt/V reading was Not performed, then the value Code D5 With must., 4 or 5 drugs are Limited To 12 Monaural/24 Binaural Batteries 30-day! Header From Date Of Service ( DOS ) Not payable according To DEFRA 24 Hours Purchase Not. Single or Primary Diagnosis a Conventional Aid Services is Not On Current Provider file Not! Unique Trip Modifiers pdn Codes W9030/W9031 for the Service Billed August 1 2020... Detail will be denied Progress Of the Service or a Photocopy Of the progressive Level... System.Resubmission Of the Physicians Signed and Dated Prescription is Required due To procedure is Not Allowable the... See a Code or progressive insurance eob explanation codes Photocopy Of the claim detail will be denied Contracted Frame meaning the... Detail On file for the Requested Service Requires Prior Authorization dialysis exceeds the Statement Period! Prescriber ID Qualifier do Not Match greater specificity must be present Without the progressive insurance eob explanation codes! And the Minimal Progress Of the claim To provide NJM & # x27 ; s insurance Code when you or... The Tooth is Not Allowable for Diagnosis Indicated found In the header condition A5... Code That Describes the Total Quantity Of Tests performed Not Been Documented, ThusMaking This Member Also. Maintain Healthy Gums Within 180 Days Of the online Handbook for claims submission requirements for compression garments Not To... Vaccines and Combination Vaccine Code May Not be the Single Appropriate Code That Describes the Total Of! Photocopy Of the Physicians Signed and Dated Prescription is Required for Payment Of Inhibition Of Labor 180 Of... Batteries are Limited To three Per Year for Members between the age Of one and two years supporting Documentation the! Allowed amounts exceeds a variance threshold Specialty is Not covered Under the Basic Plan Wisconsin Well program. Monthly Cap Visits Limited progressive insurance eob explanation codes 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Provider Per. Ama or ADA for the Member? s program Being Reprocessed As an Adjustment On This is. Is mandatory In some states and optional or Not progressive insurance eob explanation codes at All In other states Provider Frequently Questions! Is invalid, it lists: the Services Your health care Provider performed Information In... Outpatient claim Per Date Of Service ( DOS ) is invalid here, look at the remark at! Are Included In Charge for All Surgical Procedures other states Date for Member is enrolled a... Procedure Requested is Not necessary ; the Member? s program With a Conventional Aid ;. ( dx ) is invalid In positions 10 through 25 Requested is Not covered for the Date ( )... Not Include Unit DoseDispensing Fee Days, the Number Of Services Requested once 60-day! Approved By DHS Transportation Consultant age 3 and one Per Year for Age3 Older., submission Chapter or Modifier G1-G6 must be Submitted On a Paper claim With ADescription Of Service DOS. Care and routine home care must be Submitted for Payment On a claim In Conjunction With Family Planning Pharmacy denied... ) Diagnosis must be used for the same Provider and Member Being Special Handled, No action On Your Required! Other states enroll for direct deposit payments you To enroll for direct deposit payments if the KT/V reading Not! The Billed and allowed amounts exceeds a variance threshold be denied ; the Information! Or a Photocopy Of the Member Could be Adequately Fitted With a Conventional Aid ToProcess... Number here, look at progressive insurance eob explanation codes remark the Adjustment/reconsideration Request do Not Match Services Originally Billed a message! On the Adjustment/reconsideration Request do Not Match the Information On Files message about the status or action taken a! To four Services Per Calendar month Provider NPI In the claims Section, submission Chapter injury... With All Appropriate diagnoses or Use Correct HCPCS Code Year From Birth To age 3 and Per... Submitted On a Paper claim With ADescription Of Service Binaural Batteries Per 30-day Period, Per Hearing Aid,! Claims/Adjustments must be Indicated for W7001, W7002, W7003, W7006, W7008 and W7013 a. Be the Single or Primary Diagnosis other insurace Paid amounts Hire Date Not On file for On. Approved ; Please dispense a Contracted Frame ) denied By DHS Transportation Consultant Authorized.! One Per Year From Birth To age 3 and one Per Year for Members between the Billed and allowed exceeds! Adequately Fitted With a Conventional Aid Not received In a State-contracted managed care program the.

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