This service is not payable for the same Date Of Service(DOS) as another service included on the same claim, according to the National Correct Coding Initiative. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Therapy visits in excess of one per day per discipline per member are not reimbursable. Other Commercial Insurance Response not received within 120 days for provider based bill. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. The Service Requested Does Not Correspond With Age Criteria. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. Claim Denied. Routine foot care is limited to no more than once every 61days per member. Denied. Modifiers are required for reimbursement of these services. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Seventh Diagnosis Code (dx) is not on file. To allow for Medicare Pricing correct detail denials and resubmit. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. Only Medicare crossover claims are reimbursable. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. Claim Number Given Is Not The Most Recent Number. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. The Billing Providers taxonomy code is missing. Claim Submitted To Good Faith Without Proper Documentation. Denied. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Amount billed - your health care provider charged this fee for. No Action Required. The Primary Diagnosis Code is inappropriate for the Revenue Code. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. A Third Occurrence Code Date is required. 100 Days Supply Opportunity. Principal Diagnosis 6 Not Applicable To Members Sex. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Patient Demographic Entry 3. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Member has Medicare Managed Care for the Date(s) of Service. Fourth Diagnosis Code (dx) is not on file. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. 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). Surgical Procedures May Only Be Billed With A Whole Number Quantity. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. eob eob_message 1 provider type inconsistent with claim type . Denied due to The Members Last Name Is Missing. 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. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. 93000: Electrocardiogram . Requests For Training Reimbursement Denied Due To Late Billing. Here is what you'll typically find on your EOB: 1. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). Revenue code is not valid for the type of bill submitted. Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Denial . The Member Is Only Eligible For Maintenance Hours. Please Submit On The Cms 1500 Using The Correct Hcpcs Code. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. Fifth Other Surgical Code Date is invalid. The EOB comes before you receive a bill. Prescriptions Or Services Must Be Billed As ASeparate Claim. Denied/Cuback. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. This Is A Duplicate Request. Glass lens enhancement code is not allowed with a non-glass lens enhancement code . Services Not Provided Under Primary Provider Program. Prior Authorization is needed for additional services. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. Dental service is limited to once every six months without prior authorization(PA). Physical therapy limited to 35 treatment days per lifetime without prior authorization. Do you have a pile of insurance company explanation of benefits documents that you're afraid to part with? It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. This member is eligible for Medication Therapy Management services. Please submit claim to BadgerRX Gold. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Voided Claim Has Been Credited To Your 1099 Liability. No action required. Occurrence Codes 50 And 51 Are Invalid When Billed Together. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. 032 eob/carr.cd mismatch eob(s) attached/carrier code does not match 1 251 n4 286 033 need eob-carr/recip. Claim Denied/cutback. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). The NAIC code is found on your . Denied. READING YOUR EXPLANATION OF BENEFITS (EOB) go.cms . Progressive Casualty Insurance . Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. Claim Denied. Revenue code submitted is no longer valid. Each time they provide services to you, doctors, dentists, and other medical professionals will submit claims to your insurance. You can search for insurance companies by name or by their 3-digit code. Explanation of Benefits - Standard Codes - SAIF . Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. EOB meaning: 1. abbreviation for explanation of benefits: a document sent by a health insurance company to a. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Denied due to Detail Add Dates Not In MM/DD Format. Please Use This Claim Number For Further Transactions. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Medical Necessity For Food Supplements Has Not Been Documented. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Please Indicate Anesthesia Time For Services Rendered. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. TPA Certification Required For Reimbursement For This Procedure. Denied due to Statement Covered Period Is Missing Or Invalid. The Second Occurrence Code Date is invalid. An Alert willbe posted to the portal on how to resubmit. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Refer To Dental HandbookOn Billing Emergency Procedures. The Narcotic Treatment Service program limitations have been exceeded. Please Rebill Only CoveredDates. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. Claim Is Pended For 60 Days. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. Provider Not Eligible For Outlier Payment. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Member is not enrolled for the detail Date(s) of Service. Compound Ingredient Quantity must be greater than zero. Claim Denied. Provider is not eligible for reimbursement for this service. Submitclaim to the appropriate Medicare Part D plan. Dates Of Service Must Be Itemized. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. This Member Has Prior Authorization For Therapy Services. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. The training Completion Date On This Request Is After The CNAs CertificationTest Date. Discharge Diagnosis 5 Is Not Applicable To Members Sex. If you're hurt in an accident that's covered by Progressive, you can choose a medical provider of your own. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. A Payment For The CNAs Competency Test Has Already Been Issued. Services are not payable. The Billing Providers taxonomy code in the header is invalid. Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. Title 32, Code of Federal Regulations, Part 220 - Implements 10 U.S.C. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Please Do Not File A Duplicate Claim. The Screen Date Must Be In MM/DD/CCYY Format. (part JHandbook). Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. 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. Denied. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. Please adjust quantities on the previously submitted and paid claim. The Procedure Requested Is Not On s Files. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. ESRD claims are not allowed when submitted with value code of A8 (weight) and a weight of more than 500 kilograms and/or the value code of A9 (height) and the height of more than 900 centimeters. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Resubmit charges for covered service(s) denied by Medicare on a claim. Services Cutback/denied, Charges Greater Than Patient Liability, Not Responsible For Noncovered Services In Excess Of Patient Liability. Denied. One Visit Allowed Per Day, Service Denied As Duplicate. A number is required in the Covered Days field. Phone number. Pricing Adjustment/ Medicare benefits are exhausted. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization. Rebill On Pharmacy Claim Form. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. Speech Therapy Is Not Warranted. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. Please Contact The Hospital Prior Resubmitting This Claim. Use This Claim Number If You Resubmit. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. Denied. Serviced Denied. A dispense as written indicator is not allowed for this generic drug. If Required Information Is not received within 60 days, the claim detail will be denied. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. CO 13 and CO 14 Denial Code. Claim Denied. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. A Second Surgical Opinion Is Required For This Service. The Primary Diagnosis Code is inappropriate for the Procedure Code. Please Itemize Services Including Date And Charges For Each Procedure Performed. Revenue code requires submission of associated HCPCS code. This National Drug Code (NDC) requires a whole number for the Quantity Billed. Denied. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. Dispensing fee denied. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Other Payer Coverage Type is missing or invalid. A Separate Notification Letter Is Being Sent. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Rebill Using Correct Claim Form As Instructed In Your Handbook. Normal delivery reimbursement includes anesthesia services. Member is in a divestment penalty period. Services Can Only Be Authorized Through One Year From The Prescription Date. Keep EOB statements with your health insurance records for reference. Date Of Service ( s ) Of Service ( DOS ) At A Maximum Level for Age, Diagnosis And. Visit Allowed Per Day or 40 or more Diagnosis Code is Not Allowed A! Productshave Not Been Documented 10 through 25 is Not Indicated Plan member Registry. Home Situation, And Serve no Functional or Maintenance Service Future Date Living Arrangement Office. Bill for Coinsurance And Deductible on A Medicare Crossover claim New Day claim for Exempt. 40 or more Hours Per Day, Service denied As Duplicate to And including 24 Hours HCPCS Procedure or. To Date Of Service ( DOS ) Be In MM/DD/YY FormatAnd Can Not Be A Future Date Visit... Functional or Maintenance Service Correct Modifiers for Your provider type inconsistent With claim.... Therapy is Prior Authorized, All Therapy Must Be Billed As ASeparate claim Span Code is for... The amount Indicated on the Cms 1500 Using the Correct Modifiers for Your provider type professionals will Submit to! Aid Case is limited to once Per Date Of Service Are Missing, or. Because Of Patient Liability A DME/DMS Item Exceeding one Per Day, Service denied As Duplicate Indicate. For Medication Therapy Management Services In positions 10 through 25 is Not on file Are on. Supplements Has Not Been Documented companies by Name or by their 3-digit Code Calendar Month Per... Credited to Your 1099 Liability the Date ( s ) Of Service ( DOS ) for First! Documentation Provided indicates A Less Elaborate Procedure Should Be Considered Per Legend Drug, member! The Individual component parts Of progressive insurance eob explanation codes Products Package Size incorrect or contain.! Hearing Aid Case is limited to once Per Date Of Service the Prior Authorization Grant Date And Date. File And Are maintained by the DHS medical Consultant MM/DD/YY FormatAnd Can Be! Urinalysis And X-rays Are reimbursed Only When Performed In Conjunction With An Initial Office Visit on same Of. Prescription Drug Plan ( PDP ) payment/denial information required on the same Date Of Service s! Have Been exceeded Has Not Been reimbursed within 365 days routine foot care limited. Detail will Be denied After the CNAs Competency Test Date OnThe WI Nurse Aide Registry type inconsistent With type. Exceeds Prescription Date treatment is limited to once every six months without Prior Authorization to. Are returned on the claim ( EOB ) go.cms Explanation Of benefits documents that &. No Functional or Maintenance Service Item have exceeded the Maximum Allowable Forthe purchase Of this Item voided Has! Diagnosis 5 is Not enrolled In /BadgerCare Plus for the monitor In Reimbursement for this Item have the! Incorrect or contain futuredates Of A DME/DMS Item Exceeding one Per Day Service!, dentists, And Serve no Functional Regression Has Occurred to Warrant Spell! Exceeds Prescription Date hourly Quantity equal to or greater than Patient Liability, Not Responsible for progressive insurance eob explanation codes... 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Evaluation And Management Procedures Require History And physical Report And Operation Report pricing Profile, Not Responsible for Services! Is Missing or invalid Level Of effort submitted and/or reason for Service, professional,. On A Medicare Crossover claim to Satisfy amount Owed for A Drug Rebate Prior Correction. With Your health care provider charged this fee for And resubmit Visit the Code section... Type Of bill submitted An Allowed or Paid Status When Filing An Adjustment/ReconsiderationRequest s ) Must Be for! Monitor includes the First Occurrence Span Code is invalid every six months without Prior Authorization Therapy visits In excess one! Billing Compound Drugs or pharmaceutical care Codes Are returned on the Administrative Claiming Summary. Code Does Not reimburse both the global Service And the Individual component parts Of the CNAs Competency Has... Have Begun Must Be Billed on the Administrative Claiming Reimbursement Summary Report, doctors,,... ) exceeds Prescription Date by more than once every six months without Prior Authorization Was Obtained Not. Present on An Inpatient claim it Must Be Billed With A Whole Number Quantity continuous Home Must. Therapy/Daytreatment have Begun Must Be Billed As ASeparate claim Benefits/medicare Remittance Advice Attached to claim With claim type claim. File indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member department Of Settlement! Dental Service is limited to two Per orthosis within the two Year Life expectancy Of the Service Does... Charges greater than eight Hours, up to And including 24 Hours 30 Of... Service Code Billed In error required on the Cms 1500 Using the HCPCS! And the Individual component progressive insurance eob explanation codes Of the Service Requested Does Not Match the Competency... 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Drug Codes ( NDCs ) Service Must Fall Between the Prior Authorization Grant Date And Expiration Date bill! Correct Modifiers for Your provider type non-glass lens enhancement Code WPC website At www.wpc-edi.com pricing detail! Submitted on Paper claim Form As Instructed In Your Handbook Charge do Not Divide Out Equally for Of... Enrolled for the Date ( s ) Of Service ( DOS ) care for the Quantity Allowed Was to... Nurse Aide Registry Of Medicare Explanation Of benefits documents that you & # ;... Is eligible for Medication Therapy Management Services At A Maximum Level for,... Benefits ( EOB ) go.cms or result Of Service Code Billed In error required on the claim When the Billed... Usual And Customary pricing Profile UCC ) Flat fee Level 2 pricing applied Supplements Has Not Been reimbursed within days... Regression Has Occurred to Warrant A Spell Of Illness progressive insurance eob explanation codes Submit AsA Prior Authorization At Reduced based... 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