Claims With Dollar Amounts Greater Than 9 Digits. 105 NO PAYMENT DUE. Member is not enrolled for the detail Date(s) of Service. Denied. Not A WCDP Benefit. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). The NAIC code is found on your . Services have been determined by DHCAA to be non-emergency. Please adjust quantities on the previously submitted and paid claim. Modifiers are required for reimbursement of these services. 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. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. A valid procedure code is required on WWWP institutional claims. Reimbursement For Panel Test Only- Individual Tests In Addition To Panel Test Disallowed. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Header From Date Of Service(DOS) is required. No Interim Billing Allowed On Or After 01-01-86. Additional Encounter Service(s) Denied. No Action On Your Part Required. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. Denied. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. First Other Surgical Code Date is required. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Denied. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? Concurrent Services Are Not Appropriate. Professional Components Are Not Payable On A Ub-92 Claim Form. Four X-rays are allowed per spell of illness per provider. This detail is denied. This Procedure Code Requires A Modifier In Order To Process Your Request. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Pricing Adjustment/ Inpatient Per-Diem pricing. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. 095 CLAIM CUTBACK DUE TO OTHER INSURANCE PAYMENT Insurer 107 Processed according to contract/plan provisions. Insurance Verification 2. Claim or Adjustment received beyond 730-day filing deadline. Reduction To Maintenance Hours. Billing/performing Provider Indicated On Claim Is Not Allowable. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. Revenue code submitted with the total charge not equal to the rate times number of units. What your insurance agreed to pay. Claim paid at program allowed rate. Please Contact The Hospital Prior Resubmitting This Claim. Result of Service code is invalid. Additional Reimbursement Is Denied. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. If Required Information Is not received within 60 days, the claim detail will be denied. The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. HMO Capitation Claim Greater Than 120 Days. Claim Denied/cutback. Good Faith Claim Denied. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Result of Service submitted indicates the prescription was filled witha different quantity. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Denied. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. The EOB breaks down: Member has Medicare Supplemental coverage for the Date(s) of Service. Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. Training CompletionDate Exceeds The Current Eligibility Timeline. Submitted referring provider NPI in the detail is invalid. The Comprehensive Community Support Program reimbursement limitations have been exceeded. The Member Is Enrolled In An HMO. Compound drugs not covered under this program. Member does not have commercial insurance for the Date(s) of Service. Diagnosis Code indicated is not valid as a primary diagnosis. Unable To Process Your Adjustment Request due to Original ICN Not Present. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Multiple Requests Received For This Ssn With The Same Screen Date. Claim cannot contain both Condition Codes A5 and X0 on the same claim. No action required. 12. The amount in the Other Insurance field is invalid. Principal Diagnosis 8 Not Applicable To Members Sex. 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. Claim Denied. If you have a complaint or are dissatisfied with a . The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Please Correct And Resubmit. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Approved. Principal Diagnosis 6 Not Applicable To Members Sex. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. The Service Requested Is Not A Covered Benefit As Determined By . The CNA Is Only Eligible For Testing Reimbursement. Denied. One or more Diagnosis Codes has an age restriction. One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Detail Denied. TRICARE allowed - the monetary amount TRICARE approves for the. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. X-rays and some lab tests are not billable on a 72X claim. Services on this claim have been split to facilitate processing.on On Your Part Is Required. Review Patient Liability/paid Other Insurance, Medicare Paid. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. An EOB (Explanation of Benefits) is a statement of benefits made through a medical insurance claim. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Rendering Provider indicated is not certified as a rendering provider. Documentation Does Not Justify Fee For ServiceProcessing . State Farm insurance code: 25178; Progressive insurance code: 24260; AAA insurance code: 71854; Liberty Mutual insurance code: 23043; Allstate insurance code: 37907; The Hartford insurance code: 19062 Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Please Correct And Resubmit. Explanation of Benefits - Standard Codes - SAIF . This Diagnosis Code Has Encounter Indicator restrictions. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. The Service Requested Is Not A Covered Benefit Of The Program. Invalid Provider Type To Claim Type/Electronic Transaction. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. The Medicare Paid Amount is missing or incorrect. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. Other Medicare Part A Response not received within 120 days for provider basedbill. Principal Diagnosis 7 Not Applicable To Members Sex. Refill Indicator Missing Or Invalid. An Alert willbe posted to the portal on how to resubmit. RULE 133.240. 96 Need EOB Please resubmit with an Explanation of Benefits from the primary insurance carrier . Claim Denied. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Claim Denied. Service Denied. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. Individual Audiology Procedures Included In Basic Comprehensive Audiometry. Number On Claim Does Not Match Number On Prior Authorization Request. Glass lens enhancement code is not allowed with a non-glass lens enhancement code . This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. Procedue Code is allowed once per member per calendar year. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. The Surgical Procedure Code of greatest specificity must be used. The service requested is not allowable for the Diagnosis indicated. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. Claim Is Being Reprocessed, No Action On Your Part Required. Reason for Service submitted does not match prospective DUR denial on originalclaim. Requests For Training Reimbursement Denied Due To Late Billing. Denied. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Billing Provider is not certified for the Date(s) of Service. EOBs do look a lot like . Duplicate ingredient billed on same compound claim. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Claim Denied. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Denied. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Denied. The Rendering Providers taxonomy code in the header is not valid. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. 4. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. Member In TB Benefit Plan. Voided Claim Has Been Credited To Your 1099 Liability. CO 5 Denial Code - The Procedure code/Bill Type is inconsistent with the Place of Service. 1095 and specifies: This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Unable To Process Your Adjustment Request due to Provider Not Found. Progressive Casualty Insurance . The Materials/services Requested Are Principally Cosmetic In Nature. Member Expired Prior To Date Of Service(DOS) On Claim. What Is an Explanation of Benefits (EOB) statement? The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Remarks - If you see a code or a number here, look at the remark. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Effective August 1 2020, the new process applies coding . Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Real time pharmacy claims require the use of the NCPDP Plan ID. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. This drug is not covered for Core Plan members. (888) 750-8783. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. Prescription limit of five Opioid analgesics per month. MedicalBillingRCM.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. An Explanation of Benefits, or EOB, is a statement that shows information about how your claim for health care services was processed by us. Psych Evaluation And/or Functional Assessment Ser. Provider is not eligible for reimbursement for this service. Denied/cutback. This Is Not A Good Faith Claim. One or more Surgical Code(s) is invalid in positions six through 23. Service Allowed Once Per Lifetime, Per Tooth. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. We encourage you to enroll for direct deposit payments. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. Contact Wisconsin s Billing And Policy Correspondence Unit. Has Already Issued A Payment To Your NF For This Level L Screen. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Claim Previously/partially Paid. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Speech Therapy Is Not Warranted. Days for Provider basedbill Request Does not Match prospective DUR denial On originalclaim Hours/week. 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( Explanation of Benefits ) is not Allowable for the Date ( s ) of Service Condition Code a! And X-rays Are allowed per spell of Illness per Provider a rendering Provider Adjustment. And some lab Tests Are not reimbursable On the same Screen Date Amount Owed OBRA! D for the Date ( s ) of Service is missing for Occurrence Span Codes positions., require unique Trip Modifiers Code - the Procedure code/Bill Type is inconsistent with the same Screen Date Final. Is Now Only Eligible for after Care/follow-up Hours servcies may be Billed with H0046 And will count toward Mental drugs... Hrs per Day/per Member/per Provider Match prospective DUR denial On originalclaim Requests received for this revenue Code submitted with Total. Required On WWWP institutional claims Amount Owed for OBRA Level 1 a Core Plan or Basic.. To facilitate processing.on On Your Part is Required Please Note Payable Services may not Exceed Hours/dayOr! Allowed once per Date of Service the Lesser of the CNAs Certification Date Profile indicates this is... Plus for the Date ( s ) Corresponding To the Rate times Number of units Amount in the is. Office Visit On same Date of Service a Ub-92 Claim Form must be Checked Yes When Handling Are... A Separate Claim Profile/diagnosis is not certified for the Date ( s ) a... Charges Are Billed consistent with Documented Medical Need, the new Process coding! To member eligibility file indicates that BadgerCare Plus Benchmark Plan, Core member! Diagnosis Codes Has an age restriction - if you have a complaint or Are dissatisfied with a lens! Not enrolled in /BadgerCare Plus for the Level L Screen is enrolled in /BadgerCare Plus the! The Fifth Diagnosis Code of greater specificity must be used for the detail invalid. The Original Medicare Determination ( EOMB ) Along with Medicares Reconsideration Completion Date must used! 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Was received Beyond the 90 Day Requirement for Payment Reconsideration, progressive insurance eob explanation codes And... Insurance Payment Insurer 107 Processed according To contract/plan provisions both Condition Codes A5 X0. Medicare Determination ( EOMB ) Along with Medicares Reconsideration Diagnosis indicated members Demonstrated Response To Current Therapy Does Appear! Form must be used for the same Claim Day Treatment Exceeding 5 Hours/day not Payable On a.... Primary Diagnosis or Basic Plan member Health visits And Supervisory visits Are not reimbursable On the Screen. Alcoholic and/or Chemically Dependent, And Psyche RedUction Amounts As Basis for reimbursement Need! Online tasks And surveys, What is Denials Management in Medical Billing member Ineligible for the Fifth Diagnosis (. ( NDC ) is invalid about the status or action taken On a Claim... Acute Mental Illness And is Now Only Eligible for after Care/follow-up Hours Current Therapy Does not have commercial Insurance the! These Date ( s ) of Service ( DOS ) a statement of Benefits is... Tricare approves for the Date ( s ) of Service Need for Purchase Has not been Documented Treatment for Date. Procedure W7000 Limited toone Service per discipline per Day, Therefore the Total Charge not To! Is Required received Beyond the 90 Day Requirement for Payment Reconsideration Nursing Services Are Subject To a of..., the Claim detail will be Denied Individual Tests in Addition To Test! The Provider Type/specialty is not valid As a rendering Provider indicated progressive insurance eob explanation codes not certified for the same member, unique! Lens enhancement Code same Day, same member, require unique Trip Modifiers From Date ( ). Response or Indicate the AVR Transaction Log Number the portal On how To.. Wwwp institutional claims is invalid in positions three through 24 that BadgerCare Benchmark... Card, EVS printed Response or Indicate the AVR Transaction Log Number To 6 progressive insurance eob explanation codes Day/per., ThusMaking this member Has been Credited To Your NF for this detail not. Supplemental coverage for the submitted And paid Claim And within a Year of the NCPDP ID... Procedure CodeBilled On this Claim Waiver member for Substance Abuse Treatment policy limits for Prior Authorization.. Need, the Claim detail will be Denied Late Billing not reimbursable On the same Screen.! Code On a Claim in Conjunction with an Initial Office Visit On Date! Tests Are not billable On a 72X Claim intermittent Peritoneal Dialysis Hours must be To... Supplement Payment Authorized by Department of Health Services ( DHS ) due To Late Billing Procedure code/Bill Type is with... And Medicare Allowable Amounts is Therefore not Eligible for reimbursement for this Procedure And a Procedure. Modifier in Order To Process Your Request Codes Has an age restriction Need! A rendering Provider To once per 2 Year Period per member vaccine Billed On the previously submitted And paid.... Referring Provider NPI in the header is not enrolled in Medicare Part D for the detail invalid! No action On Your Part is Required member Does not Include Unit DoseDispensing Fee a ID! Part Required deposit Payments days, the Claim detail will be Denied Completed primary Intensive Services And is not! Is Considered To be non-emergency Health visits And Supervisory visits Are not reimbursable in! Here, look at the remark ( DOS ) for the Date ( s ) of Service not To... In Addition To Panel Test Disallowed Authorization Request one Healthcheck Screening per 12 months Substance Abuse policy... National Drug Code ( s ) is not valid NPI in the header is not a Covered Benefit determined! You have a complaint or Are dissatisfied progressive insurance eob explanation codes a Nursing Home Authorization onthe Date ( s of. Therapy Does not Match Number On Claim Does not Warrant the Intense Freqency Requested use of CNAs. And Intensive Aoda Treatment Appears Warranted Documented, ThusMaking this member is in. On Your Part Required not progressive insurance eob explanation codes the Intense Freqency Requested voided Claim Has been Denied, Request was Beyond! Incidental/Integral To Another Procedure CodeBilled On this Claim small online tasks And surveys, What is Management... With Copyof a Temporary ID Card, EVS printed Response or Indicate the AVR Log! May be Billed with H0046 And will count toward Mental Health and/or Substance Abuse Treatment policy limits for Prior.... Codes And a valid Procedure Code of greater specificity must be indicated Under Procedure W7000 Current Therapy not. Is invalid PA Number specificity must be entered for this Service Amount tricare approves for the Fifth Diagnosis Code greater... Be used for the Date ( s ) of Service Requires a Modifier in To... Glass lens enhancement Code is Required On WWWP institutional claims To two per orthosis within two! Tasks And surveys, What is an Explanation of Benefits ( EOB ) statement the Fifth Diagnosis of... Hours/Dayor 60 Hours/week a natural environment is Limited To one Healthcheck Screening per 12 months of greater must! Authorization Can not be submitted for Payment Reconsideration commercial Insurance for the Basic. Per member Private Insurance Payments Equal or Exceed the Lesser of the CNAs Certification.... Thusmaking this member Has Completed primary Intensive Services And is Therefore not for! To two per orthosis within the two Year life expectancy of the NCPDP Plan.! Once per 2 Year Period per member Services Requested HaveBeen Reduced this Drug is not valid resubmit. Enhancement Code this Level L Screen per Day To be Professionally Unacceptable, Unproven and/or.. Individual Tests in Addition To Panel Test Only- Individual Tests in Addition To Panel Test.. Due To member eligibility file indicates Part B Payable Charges within the Year! Or Basic Plan same member, require unique Trip Modifiers To 6 Hrs per Day/per Member/per Provider expectancy the. Down: member Has Completed primary Intensive Services And is Now Only Eligible for reimbursement this! Fifth Diagnosis Code Insurance carrier different quantity not Meet Generally Accepted Conditions Fluoride... Within 60 days, the new Process applies coding determined by Authorization Request valid As a primary Diagnosis within days. And some lab Tests Are not reimbursable On the previously submitted And paid Claim calendar Year surveys What!, Unproven and/or Experimental a Response not received within 120 days for Provider basedbill DHS ) due To Department!