After Progressive adjudicates the bill, AccidentEDI will send an 835 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. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. The Header and Detail Date(s) of Service conflict. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Procedure Code is restricted by member age. As A Reminder, This Procedure Requires SSOP. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. Denied/Cutback. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. Billed Amount Is Greater Than Reimbursement Rate. Has Already Issued A Payment To Your NF For This Level L Screen. Member has Medicare Managed Care for the Date(s) of Service. Unable To Reach Provider To Correct Claim. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. Claim contains duplicate segments for Present on Admission (POA) indicator. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. Denied due to Detail Add Dates Not In MM/DD Format. Please Attach Copy Of Medicare Remittance. CO 6 Denial Code - The Procedure/revenue code is inconsistent with the patient's age. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. This claim has been adjusted due to a change in the members enrollment. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Documentation Does Not Justify Reconsideration For Payment. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated. Reason Code 162: Referral absent or exceeded. This Procedure Is Denied Per Medical Consultant Review. Service is covered only during the first month of enrollment in the Home and Community Based Waiver. Service Denied. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Denied. Sixth Diagnosis Code (dx) is not on file. Claim Denied. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Glucocorticoids-Inhaled to Flovent. The NAIC code is found on your . Rimless Mountings Are Not Allowable Through . Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . Unable To Process Your Adjustment Request due to Claim ICN Not Found. You may begin to see additional Explanation of Benefits (EOB) codes on zero paid lines. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). What Is an Explanation of Benefits (EOB) statement? The detail From Date Of Service(DOS) is required. No Action Required on your part. Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Claim Denied Due To Invalid Occurrence Code(s). Discharge Diagnosis 4 Is Not Applicable To Members Sex. Nursing Home Visits Limited To One Per Calendar Month Per Provider. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Third Other Surgical Code Date is required. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Please Indicate One Prior Authorization Number Per Claim. One or more Diagnosis Codes has a gender restriction. Indicated Diagnosis Is Not Applicable To Members Sex. You can easily access coupons about "Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. Please Review Remittance And Status Report. Indicator for Present on Admission (POA) is not a valid value. Claim Submitted To Good Faith Without Proper Documentation. Please Correct And Resubmit. The training Completion Date On This Request Is After The CNAs CertificationTest Date. Principal Diagnosis 9 Not Applicable To Members Sex. Submit Claim To Other Insurance Carrier. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. The EOB breaks down: Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Referring Provider ID is not required for this service. Registering with a clearinghouse of your choice. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. See Physicians Handbook For Details. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. These case coordination services exceed the limit. This is Not a Bill . Member is not enrolled for the detail Date(s) of Service. If the insurance company or other third-party payer has terminated coverage, the provider should Effective August 1 2020, the new process applies coding . We encourage you to enroll for direct deposit payments. Please Indicate The Dollar Amount Requested For The Service(s) Requested. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. 032 eob/carr.cd mismatch eob(s) attached/carrier code does not match 1 251 n4 286 033 need eob-carr/recip. CPT and ICD-9- Coding 5. What your insurance agreed to pay. Admission Date does not match the Header From Date Of Service(DOS). Value Code 48 And 49 Must Have A Zero In The Far Right Position. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Service code is invalid . All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. Is Unable To Process This Request Because The Signature/date Field Is Blank. EPSDT/healthcheck Indicator Submitted Is Incorrect. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. Pricing Adjustment/ Medicare benefits are exhausted. Member is assigned to a Lock-in primary provider. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. The Lens Formula Does Not Justify Replacement. This Member Is Involved In Intensive Day Treatment, Which Is To Include Psychotherapy Services. Claim Denied. Contactmembers hospice for payment of services or resubmit with documentation of unrelated Nature of Care. Pricing Adjustment/ Ambulatory Surgery pricing applied. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Refer To Dental HandbookOn Billing Emergency Procedures. Claim cannot contain both Condition Codes A5 and X0 on the same claim. Not A WCDP Benefit. Third Other Surgical Code Date is invalid. Other Payer Coverage Type is missing or invalid. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Please Correct And Resubmit. Denied due to The Members First Name Is Missing Or Incorrect. Pharmaceutical care indicates the prescription was not filled. They might also make a digital copy available . Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. Claim Denied. employer. Submit Claim To Insurance Carrier. Please Rebill Inpatient Dialysis Only. Denied. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. The detail From Date Of Service(DOS) is invalid. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). The Information Provided Is Not Consistent With The Intensity Of Services Requested. Additional Encounter Service(s) Denied. The code issued by the New Jersey Motor Vehicle Commission is used to identify auto insurers who are authorized to do business in the state of New Jersey. Denied. the service performedthe date of the . Billing Provider Name Does Not Match The Billing Provider Number. The Non-contracted Frame Is Not Medically Justified. Prescription limit of five Opioid analgesics per month. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Pricing Adjustment/ Traditional dispensing fee applied. Denied. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Service Denied A Physician Statement (including Physical Condition/diagnosis) Must Be Affixed To Claims For Abortion Services Refer To Physician Handbook. The Requested Transplant Is Not Covered By . Transplants and transplant-related services are not covered under the Basic Plan. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. 129 Single HIPPS . The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. 13703. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. Payment may be reduced due to submitted Present on Admission (POA) indicator. There is no action required. Service(s) paid at the maximum daily amount per provider per member. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. 10. Details Include Revenue/surgical/HCPCS/CPT Codes. Maximum Number Of Outreach Refusals Has Been Reached For This Period. Discharge Diagnosis 3 Is Not Applicable To Members Sex. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Claim Denied. Member is in a divestment penalty period. Dates Of Service Must Be Itemized. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. Correction Made Per Medical Consultant Review. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). Speech Therapy Is Not Warranted. Other Coverage Code is missing or invalid. Denied. Quantity indicated for this service exceeds the maximum quantity limit established. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. AAA insurance code: 71854. If correct, special billing instructions apply. Surgical Procedure Code is not related to Principal Diagnosis Code. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. This Claim Cannot Be Processed. Do not resubmit. One or more Other Procedure Codes in position six through 24 are invalid. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. The drug code has Family Planning restrictions. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Please Submit On The Cms 1500 Using The Correct Hcpcs Code. Money Will Be Recouped From Your Account. This National Drug Code (NDC) is not covered. Insurance Appeals (BIIA). Claim Detail Denied Due To Required Information Missing On The Claim. The Other Payer Amount Paid qualifier is invalid for . The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. 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 Eighth Diagnosis Code (dx) is invalid. Requested Documentation Has Not Been Submitted. Claim Denied. Provider Documentation 4. Restorative Nursing Involvement Should Be Increased. A Previously Submitted Adjustment Request Is Currently In Process. Service Denied. The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. No Private HMO Or HMP On File. Claim Explanation Codes Request a Claim Adjustment View Fee Schedules Electronic Payments and Remittances Claims Submission Process Procedure Code Modifiers Submitting Medical Records Submitting Medicare Part D Claims ICD-10 Compliance Information The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Another PNCC Has Billed For This Member In The Last Six Months. Denied. Denied. Check Your Current/previous Payment Reports forPayment. Initial Visit/Exam limited to once per lifetime per provider. Member first name does not match Member ID. Procedure Code and modifiers billed must match approved PA. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. Second Other Surgical Code Date is required. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. This Incidental/integral Procedure Code Remains Denied. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. (Progressive J add-on) cannot include . Bundle discount! Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Training Completion Date Is Not A Valid Date. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. Please Indicate Mileage Traveled. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Member is assigned to an Inpatient Hospital provider. Pricing Adjustment/ Paid according to program policy. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Paid In Accordance With Dental Policy Guide Determined By DHS. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. You can also use it to track how you and your family use your coverage. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. The Maximum Prior Authorized Service Limitation Or Frequency Allowance Has Been Exceeded. Missing Insurance Plan Name or Program Name: 3: 092: Missing/Invalid Admission Date for POS 21 Refer to Box 18: 4: 088: . This is a duplicate claim. 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. Referring Provider is not currently certified. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Billing Provider Type and Specialty is not allowable for the Place of Service. Procedure Code is not payable for SeniorCare participants. Previously Denied Claims Are To Be Resubmitted As New Day Claims. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Reimbursement For Panel Test Only- Individual Tests In Addition To Panel Test Disallowed. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Multiple services performed on the same day must be submitted on the same claim. Denied. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. Services Requested Do Not Meet The Criteria for an Acute Episode. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Prescriber ID Qualifier must equal 01. We Are Recouping The Payment. The Rendering Providers taxonomy code in the detail is not valid. Use The New Prior Authorization Number When Submitting Billing Claim. WorkCompEDI, Inc. Date of services - the date you received the care. Pricing Adjustment/ Medicare pricing cutbacks applied. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. 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. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. EOB meaning: 1. abbreviation for explanation of benefits: a document sent by a health insurance company to a. Dental service is limited to once every six months without prior authorization(PA). Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Member In TB Benefit Plan. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. Revenue code requires submission of associated HCPCS code. Pricing Adjustment/ Pharmacy dispensing fee applied. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span.

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