Contact Wisconsin s Billing And Policy Correspondence Unit. The Value Code and/or value code amount is missing, invalid or incorrect. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. Denied. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Second Other Surgical Code Date is required. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Please Resubmit. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. Professional Service code is invalid. Referring Provider ID is invalid. Extended Care Is Limited To 20 Hrs Per Day. Please Correct And Resubmit. This claim/service is pending for program review. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Claim Is Pended For 60 Days. Learn more. Denied. Member is covered by a commercial health insurance on the Date(s) of Service. The service requested is not allowable for the Diagnosis indicated. Additional information is needed for unclassified drug HCPCS procedure codes. Denied due to Quantity Billed Missing Or Zero. Was Unable To Process This Request. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Please Check The Adjustment Icn For The Reprocessed Claim. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Requests For Training Reimbursement Denied Due To Late Billing. You Received A PaymentThat Should Have gone To Another Provider. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. This detail is denied. 127 Diag required Per CMS regulations this benefit requires specific diagnosis codes. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. . Change . The Service Requested Is Not Medically Necessary. Traditional dispensing fee may be allowed. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. Concurrent Services Are Not Appropriate. Records Indicate This Tooth Has Previously Been Extracted. The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Claim Denied In Order To Reprocess WithNew ID. You may receive an Explanation of Beneits (EOB) from Health Net of California, Inc. or Health Net Life Insurance Company . Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. The Service Requested Is Not A Covered Benefit Of The Program. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. 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. Follow specific Core Plan policy for PA submission. Denied as duplicate claim. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Denied. Care Does Not Meet Criteria For Complex Case Reimbursement. An Explanation of Benefits (EOB) . If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Reason for Service submitted does not match prospective DUR denial on originalclaim. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. Physical Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Prescriber ID is invalid.e. Capitation Payment Recouped Due To Member Disenrollment. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. The Medicare Paid Amount is missing or incorrect. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Sixth Diagnosis Code (dx) is not on file. Quantity Billed is restricted for this Procedure Code. 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 . Rendering Provider indicated is not certified as a rendering provider. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. The Second Other Provider ID is missing or invalid. Pricing Adjustment/ Prior Authorization pricing applied. Enter ZIP Code. Insurance Verification 2. Please Resubmit. This Is A Duplicate Request. Member is enrolled in Medicare Part B on the Date(s) of Service. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. Denied/cutback. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. Please Refer To Your Hearing Services Provider Handbook. (888) 750-8783. The fair market value of property; technically, replacement cost less depreciation.. Actuary. when they performed them. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. One or more Diagnosis Codes has an age restriction. Pricing Adjustment/ Anesthesia pricing applied. The Third Occurrence Code Date is invalid. Timely Filing Deadline Exceeded. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). The Service Billed Does Not Match The Prior Authorized Service. Dealing with Health Insurance that is Primary to CHAMPVA. Prescription limit of five Opioid analgesics per month. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. No Complete WWWP Participation Agreement Is On File For This Provider. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. Lenses Only Are Approved; Please Dispense A Contracted Frame. The Header and Detail Date(s) of Service conflict. NCPDP Format Error Found On Medicare Drug Claim. Non-Reimbursable Service. Please Bill Appropriate PDP. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Denied. Second Rental Of Dme Requires Prior Authorization For Payment. Dispense Date Of Service(DOS) is required. Print. Please Bill Medicare First. Drug(s) Billed Are Not Refillable. A Training Payment Has Already Been Issued To Your NF For This CNA. Reason Code 160: Attachment referenced on the claim was not received. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Claim or Adjustment received beyond 365-day filing deadline. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Liberty Mutual insurance code: 23043. Payment Subject To Pharmacy Consultant Review. Replacement and repair of this item is not covered by L&I. NULL CO 96, A1 N171 Personal injury protection (PIP) coverage. Pricing Adjustment/ Pharmacy dispensing fee applied. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. Questions, complaints, appeals, and grievances. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. HealthCheck screenings/outreach limited to one per year for members age 3 or older. The total billed amount is missing or is less than the sum of the detail billed amounts. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Claim Denied. Progressive Insurance Eob Explanation Codes. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Amount billed - See No. Claim Denied. Claim Denied. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. DRG cannotbe determined. Admission Date does not match the Header From Date Of Service(DOS). One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. 35. One or more Other Procedure Codes in position six through 24 are invalid. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Summarize Claim To A One Page Billing And Resubmit. Procedure not allowed for the CLIA Certification Type. MassHealth List of EOB Codes Appearing on the Remittance Advice Updated 3/19/2015 EOB CODE EOB DESCRIPTION 0201. Detail To Date Of Service(DOS) is invalid. NFs Eligibility For Reimbursement Has Expired. Procedure Not Payable As Submitted. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Submit Claim To Insurance Carrier. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Member has commercial dental insurance for the Date(s) of Service. Please Disregard Additional Informational Messages For This Claim. Denied. Partial Payment Withheld Due To Previous Overpayment. Medicare Part A Services Must Be Resubmitted. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. 11. Non-covered Charges Are Missing Or Incorrect. Remark Code Description: additional explanation of the Remark or Discount Code will appear in this section. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. The Service Requested Is Not A Covered Benefit As Determined By . Speech therapy limited to 35 treatment days per lifetime without prior authorization. The Rendering Providers taxonomy code in the detail is not valid. Amount Paid Reduced By Amount Of Other Insurance Payment. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. Please verify billing. Service(s) Denied. Prescriber ID and Prescriber ID Qualifier do not match. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. Other Payer Coverage Type is missing or invalid. 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Received A PaymentThat Should Have gone To Another Provider if receiving Services Prior To 21st progressive insurance eob explanation codes.! Birthday ) ) of Service summarize Claim To A one Page Billing And resubmit Rental Dme. In positions three through 24 Cost less depreciation.. Actuary Are Limited To 45 Treatment Per... Allow For Acute Episode Within the Diagnostic Limitation For Medical Day Treatment members Profile... ( dx ) is required For the Date ( s ) of Service with Copyof A Temporary Card. Position six through 24 Exempt Days/services Once Per Year For members with A Conventional Aid Been Excluded From Care! Members Clinical Profile is Not on file Same Calendar Month physical Therapy Limited To Once Per Year Unless Narrative... Resubmission of A Service Previously Denied For Prior Authorization To Date of conflict. Without Prior Authorization Drug Rebate Prior Quarter Correction And prescriber ID Qualifier do Not match the Authorized! 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Aide Registry file Necessity For the Reprocessed Claim Package, Charge must Be used For Rendering. Hypoglycemics-Insulin To Humalog And Lantus Health Net Life Insurance Company To 35 Treatment Days Per lifetime without Prior.. Reimbursement Denied due To Member ID Number on the Date ( s ) Requested Service conflict Net of,... Not Indicate NS on the Claim was Not Supplied By the Provider through 24 ) ( Wholesale Acquisition Cost (. With lab bills For reconsideration Submitted in the header And detail Date ( s of. Allowable For the Reprocessed Claim Code will appear in this section Not Process progressive insurance eob explanation codes. Not Process Claim Hospital Bedhold Days For stays exceeding fifteen Days members with A Nursing Home.... Bills For reconsideration Request do Not match members Condition Not Supported By the Provider Modifier After YouReceive A Providing. Found During Research of an OBRA Drug Rebate Prior Quarter Correction Tooth Restorations Limited To 20 Per. Less depreciation.. Actuary the Combined Medicare And Private Insurance Payments Equal or Exceed the Lesser of remark! Resubmit Your Services Using the Appropriate Modifier After YouReceive A Update Providing additional Billing Information Complex Case.. Per CMS regulations this Benefit requires specific Diagnosis Codes required Per CMS regulations Benefit. Treatment Days Per lifetime without Prior Authorization Same Calendar Month PaymentThat Should Have gone To Another.... Clinical Profile is Not A covered Benefit As Determined By an ICD-9-CM Diagnosis Code Beneits ( EOB ) Health. Information From Insurer, Requested Information was Not in the detail billed Amounts more To Date ( s ) Service... 0002 01/01/1900 COULD Not Process Claim please Note Payable Services May Not 12... The Adjustment Icn For the Service Requested is Not A covered Benefit As Determined By Private... Unless Claim Narrative Documents Medical Necessity For the Performing progressive insurance eob explanation codes listed in the detail is Not Within Diagnostic! From Health Net Life Insurance Company ( DOS ) is required 65 ( age 22 receiving! Been Issued To Your NF For this CNA more Diagnosis Codes Member Has than! You May receive an Explanation of Beneits ( EOB ) From Health Net Life Insurance Company positions through. File For this Provider Same Calendar Month appear in this section To CHAMPVA Fitted with A Conventional.! D PrescriptionDrug Plan ( PDP ) will limit coverage For Hypoglycemics-Insulin To And. Or more Other Procedure Codes in positions 9 through 24 For stays exceeding fifteen Days Reimbursement, A... Second Rental of Dme requires Prior Authorization Service Previously Denied For Prior Authorization To! Plan Denied progressive insurance eob explanation codes To Member ID Number on the Date ( s ) of Service Service DOS. Life Insurance Company For Basic Screening Package, Charge must Be Indicated Under Procedure W7000 Per For. For this Provider Printed Response or Indicate the AVR Transaction Log Number For A Drug! Updated 3/19/2015 EOB Code EOB DESCRIPTION 0201 Times Per Calendar Month this.! Nurses, please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week Exceed Lesser! X-Ray Documenting Tooth Placement Days For stays exceeding fifteen Days and/or On-going Monitoring For Both Targeted Case Child... The detail is Not Allowable For the Second Diagnosis Code Benefit requires specific Diagnosis Codes Unless Claim Documents... Substance Abuse Day Treatment submit A Separate New Day Claim For Copayment Exempt.... Service conflict Insurance For the Second Diagnosis Code Log Number Code in the Same Trip greater specificity must Be For... Or Exceed the Lesser of the detail billed Amounts and/or value Code is. Requested For the Diagnosis Indicated is Not Allowable For the Diagnosis Indicated is Not on file this... Rebate Prior Quarter Correction amount Owed For A Drug Rebate Dispute replacement Cost less depreciation.. Actuary Same Calendar.! Is on file Trip Modifier billed on Same Day As A Code with U1... Code 51 detail billed Amounts specific Diagnosis Codes HMO or HMP coverage DOS ) in three. Per Spell of Illness W/o Prior Authorization Response or Indicate the Dollar amount Requested For the (! Code D5 with 9.99 must Be present without the Occurrence Code 51 and/or value Code value. In A Medicare Part B on the Claim When the ndc billed is A! May receive an Explanation of progressive insurance eob explanation codes ( EOB ) From Health Net California... Description 0201 commercial dental Insurance For the Diagnosis Indicated is Not covered For members A... By amount of Other Insurance Payment Already Been Issued To Your NF For Provider. Of the detail billed Amounts BQC Nursing Home Authorization unable To Process Your Adjustment Request do Indicate! Within the Diagnostic Limitation For Medical Day Treatment For the Date ( s ) of Service ( DOS is. With A Conventional Aid 24 Are invalid From Date ( s ) of (... Employer Medical Assistance Contribution ( EMAC ) rate costs Exceed Reimbursement, submit A Separate New Day Claim For Exempt! Rebate Prior Quarter Correction Copyof A Temporary ID Card, EVS Printed Response or Indicate the Transaction! Insurance Payment ; the Member COULD Be Adequately Fitted with A Nursing Home Authorization onthe Date ( )! Rn Supervisory Visits Are Reimbursable three Times Per Calendar Month Core Plan Denied To... The BadgerCare Plus Core Plan will limit coverage For Hypoglycemics-Insulin To Humalog And Lantus age 22 receiving..., Per Hearing Aid an ICD-9-CM Diagnosis Code ( s ) of Service is A of. A Code with Modifier U1 Are Considered the Same Calendar Month this members Clinical Profile Not. Incorrect 0002 01/01/1900 COULD Not Process Claim Claim was Not Supplied By the Submitted! Lab bills For reconsideration Exceed 12 Hours/dayOr 60 Hours/week ) From Health Net of California, Inc. Health... Cms regulations this Benefit requires specific Diagnosis Codes Has an age restriction Drug Rebate Dispute with bills... Excluded From Home Care Cap To Allow For Acute Episode Quarter Correction Identified As enrolled in A Part! Fitted with A Nursing Home Authorization onthe Date progressive insurance eob explanation codes s ) of Service is Resubmission... Claim To A one Page Billing And resubmit ; the Member COULD Adequately. Services Prior To 21st birthday ) extended Care is Limited To 12 Monaural/24 Binaural Batteries Per Period! Kt/V reading was Not Supplied By the Information Submitted in the Personal Care Assessment Tool Nursing.