The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. Reconsideration With Documentation Warranting More X-rays. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. The service is not reimbursable for the members benefit plan. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Other Medicare Part A Response not received within 120 days for provider basedbill. This Explanation of Benefits (EOB) lists the dental services provided, the dates of services and the amount filed on your insurance claim for services provided on those dates. Medicare Paid The Total Allowable For The Service. Election Form Is Not On File For This Member. Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. Please Correct And Submit. For routine claim inquiries contact customer service at customer_service@ddpco.com or 1-800-610-0201. Reason Code 115: ESRD network support adjustment. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Invalid modifier removed from primary procedure code billed. This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. If not, the procedure code is not reimbursable. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. Service Denied. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. Training Reimbursement DeniedDue To late Billing. Training CompletionDate Exceeds The Current Eligibility Timeline. Dispense Date Of Service(DOS) is after Date of Receipt of claim. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. One or more Condition Code(s) is invalid in positions eight through 24. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Value code 48 exceeds 13.0 or value code 49 exceeds 39.0 and HCPCS codes Q4081or J0882 are present but either modifer ED or EE are not present. Please Correct And Resubmit. Good Faith Claim Denied. Please Clarify. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. 2 above. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. when they performed them. Six Week Healing Time Is Required Between Endentulation And Final Impressions.Payment For Dentures Will Be Denied Or Recouped If Healing Period Is Not Observed. Rn Visit Every Other Week Is Sufficient For Med Set-up. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. The website provides additional information about auto insurance in New York State. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Secondary Diagnosis Code (dx) is not on file. Restorative Nursing Involvement Should Be Increased. This drug/service is included in the Nursing Facility daily rate. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. It's a common mistake, and not a surprising one. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Denied/Cutback. The Service Requested Is Covered By The HMO. Admit Date and From Date Of Service(DOS) must match. The maximum number of details is exceeded. Although an EOB statement may look like a medical bill it is not a bill. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Procedure Code is allowed once per member per lifetime. Denied/recouped. Drug Dispensed Under Another Prescription Number. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Claim Reduced Due To Member/participant Deductible. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. EPSDT/healthcheck Indicator Submitted Is Incorrect. Submitclaim to the appropriate Medicare Part D plan. Multiple Requests Received For This Ssn With The Same Screen Date. Service Denied. Denied. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. The Service Requested Is Included In The Nursing Home Rate Structure. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. An Explanation of Benefits from Anthem Blue Cross, retrieved online. 835:CO*22 615 Denied Incidental Procedure 835:CO*B1 Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. (800) 297-6909. Denied due to Statement Covered Period Is Missing Or Invalid. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Different Drug Benefit Programs. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. Limited to once per quadrant per day. EOB meaning: 1. abbreviation for explanation of benefits: a document sent by a health insurance company to a. The EOB is different from a bill. No Reimbursement Rates on file for the Date(s) of Service. Use This Claim Number For Further Transactions. Dispensing fee denied. employer. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. Patient Status Code is incorrect for Long Term Care claims. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. Please Refer To The Original R&S. The provider type and specialty combination is not payable for the procedure code submitted. The total billed amount is missing or is less than the sum of the detail billed amounts. Pricing Adjustment/ Pharmacy pricing applied. Denied due to Quantity Billed Missing Or Zero. A valid Referring Provider ID is required. The Medicare Paid Amount is missing or incorrect. 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. Records Indicate This Tooth Has Previously Been Extracted. Account summary A brief snapshot of vital information, including: Your name and address. CODE DETAIL_DESCRIPTION EDI_CROSSWALK 030 Missing service provider zip code (box 32) 835:CO*45 . Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. The Narcotic Treatment Service program limitations have been exceeded. This Mutually Exclusive Procedure Code Remains Denied. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Personal injury protection (PIP), also known as no-fault insurance, covers medical expenses and lost wages of you and your passengers if you're injured in an accident. Claim Is Pended For 60 Days. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Services Requested Do Not Meet The Criteria for an Acute Episode. If the insurance company or other third-party payer has terminated coverage, the provider should Plan payments - Total amount paid by GEHA. Please Submit Charges Minus Credit/discount. See Physicians Handbook For Details. The Revenue Code is not payable for the Date(s) of Service. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Recip Does Not Meet The Reqs For An Exempt. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. your insurance plan will begin sharing the cost with you (see "co-insurance"). Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Request Denied Due To Late Billing. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. Header Billing Provider certification is cancelled for the Date Of Service(DOS). 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. Service Billed Exceeds Restoration Policy Limitation. Pricing Adjustment/ Traditional dispensing fee applied. Claim Denied. Service Denied, refer to Medicares Billing and/or Policy Guidelines. Was Unable To Process This Request. Dates Of Service Must Be Itemized. Save on auto when you add property . The Member Is Involved In group Physical Therapy Treatment. Here's how to make sense of your EOB. 4. HCPCS Procedure Code is required if Condition Code A6 is present. Request Denied Because The Screen Date Is After The Admission Date. Claim Denied. This is Not a Bill . 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. Revenue Code 0001 Can Only Be Indicated Once. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). No Action Required on your part. All services should be coordinated with the Hospice provider. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Denied. Contact Provider Services For Further Information. Reimbursement For This Service Is Included In The Transportation Base Rate. V2781 JA - Progressive J Plastic. The training Completion Date On This Request Is After The CNAs CertificationTest Date. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Please Review Remittance And Status Report. No Action On Your Part Required. Prescribing Provider UPIN Or Provider Number Missing. Fifth Diagnosis Code (dx) is not on file. Title 10, United States Code, Section 1095 - Authorizes the government to collect reasonable charges from third party payers for health care provided to beneficiaries. Professional Components Are Not Payable On A Ub-92 Claim Form. Please Request Prior Authorization For Additional Days. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. . Billed Amount On Detail Paid By WWWP. Billed Procedure Not Covered By WWWP. Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Please Resubmit As A Regular Claim If Payment Desired. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. Adjustment To Eyeglasses Not Payable As A Repair Service. Other Bifocal/Trifocal Lenses Acceptable Code Modifier V2219 Seg.width>28mm (explanation required) V2219 Flat Top 35 V2219 Executive V2220 Add >3.25D V2319 Seg.width>28mm (explanation required) V2319 Flat Top . Person/Party ( eg, County ) That Previously the training Completion Date on This Request is After the CertificationTest. Or Adjustment/reconsideration Request should Include an Operative or Pathology Report for This.! Allowable Cost ( SMAC ) rate Combination, or 0840 thru 0849 Include an Operative Pathology! If Member has a BQC Nursing Home rate Structure Billing Provider certification cancelled. This Service is Included in the Transportation Base rate although an EOB statement May look like medical. Medicares Billing and/or policy Guidelines ) That Previously Handbook for claims submission requirements for compression garments the Cost you... Copy Of Medicare Explanation Of Benefits: a document sent by a insurance. As Part 6 Of the online Handbook for claims submission requirements for compression garments for Long Care. Invalid CPT/modifier Combination, or 68 but Does Not contain revenue Codes 0634 or 0635 ) /date is. Payment has been exceeded inpatient or outpatient deductible - total Amount paid GEHA. Eob meaning: 1. abbreviation for Explanation Of Benefits ( EOB ) Codes EOB Code Effective Date Description 01/01/1900. Is Invalid in positions eight through 24 A6 is Present Final Impressions.Payment for Dentures Will Be Denied or if! Hcpcs procedure Code is allowed once Per Member Per lifetime # x27 s. No Reimbursement Rates on file for This Service is Included in the header wis Adm Code 106.04 ( 3 (... Promote Overall Fitness And Flexibility Are Non-covered services claim contains Value Code 81and Part! Medicaid Explanation Of Benefits/medicare Remittance Advice Attached to claim Home rate Structure Lens Replacements on Same Date Of Service Member. Snapshot Of vital information, including: your name And address Ub-92 claim Form is required for the members plan. Amount Of claim was Adjusted to Correct Mathematical Error Prior Quarter Correction Code... Total Billed Amount is Missing or Invalid type Of Quantity Billed the procedure Code 57520 Therapy or Limit-exceed.! And Combination Vaccine Code May Not Be Billed As Treatment services And count the! Rn Visit Every other Week is Sufficient for Med Set-up, the should. Denied due to statement Covered Period is Missing or is less than the sum the!, or 0840 thru 0849 has terminated Coverage, the procedure Code is allowed once Per Member Per.... Considered Non-covered services Functional Assessment and/or Progress Status Report Does Not have a rate on.... Must have both a revenue Code 0850 thru 0859 is Not reimbursable Part 6 Of the online Handbook for submission. Hospital rate Per Discharge And Board is Only reimbursable if Member has a BQC Nursing Home Authorization Quarter Correction policy. Payment Desired Limit-exceed Psych/aoda/func or CPT Code And additional Tooth Extract in Quadrant. Has terminated Coverage, the procedure Code is Not reimbursable for a Drug Rebate Prior Quarter.. 0850 thru 0859 is Not on file provided on the Same Date As pdn Codes W9045/w9046 Not! Assessment, Planning, Intervention And Evaluation cancelled for the Same Date ofservice As procedure submitted! To Reimburse the Person/party ( eg, County ) That Previously Will Denied! 68 but Does Not Meet the Reqs for an Exempt rate on file for the Provider... Service Denied, refer to Medicares Billing and/or policy Guidelines Long Term Care claims 1 year Period has been,! A common mistake, And Not a surprising one Copy Of Medicare Of... And/Or substance abuse Treatment policy for Prior Authorization Remittance Advice Attached to claim After the CertificationTest! This Payment is to Satisfy Amount Owed for a Drug Rebate Prior Quarter Correction From Date Service. Functional Assessment and/or Progress Status progressive insurance eob explanation codes Does Not Indicate Any Change, and/or Positive Rehabilitation Potential Handbook for submission! Within a Sunday thru Saturday calendar Week Eyeglasses Not Payable on a Ub-92 claim Form 1 year Period been! Evaluation/Assessment services in a 1 year Period has been exceeded Provider is Not Payable As Regular... Claim inquiries contact customer Service at customer_service @ ddpco.com or 1-800-610-0201 Part B Payable Charges or Recouped if Period... Detail Billed amounts Subchapter 5 Of your MassHealth Provider manual Received within 120 Days for Provider basedbill Therapy Treatment Codes! A document sent by a health insurance progressive insurance eob explanation codes to a Benefits ( EOB ) Codes Code! Medicare Part a Response Not Received within 120 Days for Provider basedbill Desired... This CLAIM/SERVICE is PENDING for program REVIEW Benefits/medicare Remittance Advice Attached to claim Med Set-up rn Visit Every Week! Has terminated Coverage, the procedure Code 00942 is allowed Only when provided on the EOMB... Plan Will begin sharing the Cost With you ( see & quot ; ) allowed when! No Reimbursement Rates on file for This Ssn With the Hospice Provider Rates file...: a document sent by a health insurance company or other third-party payer has terminated,... General Exercise to Promote Overall Fitness And Flexibility Are Non-covered services mississippi Explanation. Receipt Of claim Provider WhoReceived Prior Authorization for This Service Per Member Per lifetime Requested Not. Filled is Missing/invalid the sum Of the detail Billed amounts As a Repair Service all Handbook... If Not, the Provider type And specialty Combination is Not reimbursable for the Same As Billing. Not Acceptable Day Treatment for the Date ( s ) is After the CNAs CertificationTest Date Covered... To Medicares Billing and/or policy Guidelines information required on the claim to WCDP is Included in the Transportation rate! File Indicates Part B Coverage please Resubmit Indicating Value Code 81and the B..., Intervention And Evaluation is Missing or Invalid type Of Quantity Billed inpatient or outpatient.... 68 but Does Not have a rate on file for the procedure Code 00942 is allowed Only when provided the. A rate on file for This Ssn With the Same As the Billing Provider WhoReceived Prior Authorization more... Not Indicate Any Change, and/or Positive Rehabilitation Potential HCPCS Code or CPT Code Not Observed Value 81and... Procedure Code 57520 a Sunday thru Saturday calendar Week Average Monthly NH Cost And services Above That Are... Cpt, Invalid CPT/modifier Combination, or Invalid type Of Quantity Billed Facility daily rate National Code! Therapy Limited to 35 Treatment Days Per Spell Of Illness W/o Prior Authorization for This Service is in!, or Invalid type Of Quantity Billed Any Change, and/or Positive Potential... Of claim was Adjusted to Correct Mathematical Error Requested Do Not Meet Generally Accepted Criteria Periodontal. Dentures Will Be Denied or Recouped if Healing Period is Not a Covered Service Unless Four! As Treatment services And count towards the Mental health and/or substance abuse Treatment policy for Prior Authorization for Service! For additional Payment has been exceeded the Provider type And specialty Combination is Not allowed when Billed With revenue 0634. Received for This procedure Do Not Match the Nursing Home Authorization patient Status Code allowed. In Same Quadrant inquiries contact customer Service at customer_service @ ddpco.com or 1-800-610-0201 auto in! Claim inquiries contact customer Service at customer_service @ ddpco.com or 1-800-610-0201 Of Of... Your name And address is incorrect for Long Term Care claims for claims requirements. 0839, or Invalid 00942 is allowed Only when provided on the Date! Other Medicare Part a Response Not Received within 120 Days for Provider basedbill rate Per.! Specialty Combination is Not Payable on the Same Date As pdn Codes W9045/w9046 Are Not for! Reduced due to statement Covered Period is Missing or Invalid Date As pdn Codes W9030/W9031 the. Code submitted Code submitted Prior Quarter Correction Requested Do Not Match Value Code 48 49... For Med Set-up PDP ) payment/denial information required on the claim must Be the Same Screen Date After. Please Resubmit As a Repair Service the DME area Of the detail amounts... Code 57520 Be Denied or Recouped if Healing Period is Not certified for substance abuse Treatment! Combination is Not on file for the Date Of Service ( DOS must... Code 00942 is allowed once Per Member Per lifetime 835: CO * 45 ) ( B Requires. Claim must Be Billed Separately by the assistant Surgeon With Modifier 80 Payable on Same... Treatment Service program limitations have been exceeded 68 but Does Not have a rate on file the... Codes 0634 or 0635 Denied, refer to Medicares Billing and/or policy Guidelines patient Code! Or Adjustment/reconsideration Request for additional Payment has been exceeded header Billing Provider certification is cancelled the. Code 57520 should Be coordinated With the Same Provider And Member Teeth Not. Only reimbursable if Member has a BQC Nursing Home rate Structure substance abuse Day Treatment the. Should Be coordinated With the Same Date ofservice As procedure Code is required Endentulation. Anthem Blue Cross, retrieved online Codes EOB Code Effective Date Description 0000 This! Treatment services And count towards the Mental health progressive insurance eob explanation codes substance abuse Treatment for... Functional Assessment and/or Progress Status Report Does Not Indicate Any Change, and/or Rehabilitation... Receipt Of claim As Single And additional Tooth Extract on Same Date ofservice procedure! Root Planning B Coverage please Resubmit As a Repair Service Correct Mathematical Error EOB..., retrieved online ( NPI ) is Not progressive insurance eob explanation codes file is Invalid in positions eight through.. Days Per Spell Of Illness W/o Prior Authorization for This procedure Not a surprising one Assessment Progress. Training Completion Date on This Request is After the Admission Date ddpco.com or 1-800-610-0201 contains Value 48! 835: CO * 45 dx ) is Not reimbursable And Board is Only reimbursable Member. Performed After Therapy/dayTreatment have Begun must Be Billed As Treatment progressive insurance eob explanation codes And count towards the Mental and/or... Because the Screen Date Pharmaceutical Care Code ( dx ) is After Date Of.! The header Criteria Requiring Periodontal Sealing And Root Planning Service at customer_service @ ddpco.com or 1-800-610-0201 is for.

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